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N. Muljadi



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    O07 - Supportive and Surgical Care (ID 136)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O07.02 - The preferred and actual levels of involvement in decision-making among patients considering adjuvant chemotherapy (ACT) for non-small-cell lung cancer (NSCLC). (ID 2038)

      10:40 - 10:50  |  Author(s): N. Muljadi

      • Abstract
      • Presentation
      • Slides

      Background
      Patients with cancer have varying preferences for involvement in decision-making between active, collaborative and passive roles. Previous studies suggest that many patients prefer a more active role than they experienced, and a more active role over time[MSA(1] . We sought the preferred and actual level of involvement in decision-making among patients considering ACT after resection of early NSCLC.

      Methods
      98 patients completed a self-administered questionnaire at baseline (before ACT, if they were having it) and at 6 months (after ACT, if they had it). Preferred and actual level of involvement in decision-making were assessed by the Control Preferences Scale (CPS) and trichotomised into active, collaborative, and passive roles. Health-related quality of life (HRQL) data were assessed by the Patient DATA Form. Differences on the original CPS scale between preferred and actual roles and between preferred roles over time were assessed with the Wilcoxon signed-rank test. Determinants of preference for an active role were assessed with chi-square tests of association in 2x2 tables, summarising by odds ratios (ORs). Wilcoxon rank-sum (WRS) tests were used to assess differences in survival benefits required to make ACT worthwhile between patients preferring active and less active roles.

      Results
      Most patients were male (55%) with a median age of 64 years (range, 43-79 years), married (74%) and previous smokers (82%). The majority had had a lobectomy (85%), adenocarcinoma histology (63%), and half (46%) had stage II disease. 83 patients decided to have ACT (85%), 15 declined ACT (15%). ACT was most commonly 4 cycles (71%) of cisplatin/ vinorelbine (73%). Preferred role in decision-making at baseline (n=98) was active in 26 (27%), collaborative in 46 (47%), and passive in 26 (27%); and at 6 months (n=73) was active in 15 (21%), collaborative in 37 (51%) and passive in 21 (29%). Preferred decision-making roles were stable over time (p=0.5). Actual decision-making roles at baseline (n=98) were active in 24 (24%), collaborative in 47 (48%), and passive in 27 (28%). There was concordance between preferred and actual decision-making roles at baseline (p=0.4). Preferring a more active role was associated with university education (p=0.02, OR 2.9) and worse HRQL during ACT: physical well-being (p=0.05, OR 4.4), overall well-being (p=0.02, OR 5.5), sleep (p=0.03, OR 8.4) and shortness of breath (p=0.01, OR 7.6). Patients who preferred an active decision-making role judged larger survival benefits to make ACT worthwhile than patients who preferred a passive role (eg extra survival time of 1 year v 6 months, WRS p=0.03; extra survival rate of 17.5% v 2.5%, WRS p <0.01).

      Conclusion
      Patients with recently resected NSCLC varied in their preferred roles in decision-making about ACT with most patients preferring a collaborative role. Their preferences were stable over time, and were concordant with their perceived actual role in decision-making at baseline. Preferences for an active role in decision-making were associated with judging larger survival benefits necessary to make ACT worthwhile. Clinicians should elicit and consider patients’ preferences for involvement in decision-making when discussing ACT for NSCLC.

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    P1.12 - Poster Session 1 - NSCLC Early Stage (ID 203)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 2
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      P1.12-010 - Lung cancer clinicians' preferences for adjuvant chemotherapy (ACT) in non-small-cell lung cancer (NSCLC): what makes it worthwhile? (ID 1498)

      09:30 - 09:30  |  Author(s): N. Muljadi

      • Abstract

      Background
      Clinicians play an important role helping patients make decisions about ACT, but their views about trade-offs between the benefits and harms of ACT may differ from those of their patients. We sought to determine the minimum survival benefits that lung cancer clinicians judged sufficient to make ACT in NSCLC worthwhile, the factors associated with these judgements, and comparisons with the preferences of their patients.

      Methods
      82 lung cancer clinicians (medical oncologists & thoracic surgeons) completed a self-administered questionnaire. The time trade-off method was used to determine the minimum survival benefits judged sufficient to make ACT worthwhile in 4 hypothetical scenarios. Baseline survival times were 3 years and 5 years and baseline survival rates (at 5 years) were 50% and 65%. Patients’ preferences were those of 122 patients considering ACT for NSCLC elicited in a related study using similar methods. Differences between groups were assessed by 2-sample non-parametric tests. Determinants of preferences were assessed by univariable comparison after normal score transformation. Variance was assessed with the Ansari-Bradley rank test.

      Results
      Most clinicians were male (75%) with a median age of 43 years (range 28-65), had 5 or more years of professional experience (69%), were married (92%), and had dependent children (72%). More were medical oncologists (63%) than thoracic surgeons (31%). The median benefit judged sufficient (by 50% of clinicians) was an extra 9 months (IQR 6-12 months) beyond survival times of both 3 years and 5 years, and an extra 5% (IQR 5-10%) beyond 5-year survival rates of both 50% and 65%. Medical oncologists, compared with thoracic surgeons, judged smaller benefits sufficient to make ACT worthwhile (median benefit 8 months v 12 months, p=0.03). Clinicians’ preferences, compared with patients’ preferences, had the same median benefit (9 months survival time, 5% survival rate) but varied over a smaller range (IQR, 6-12 months v 1-12 months, p<0.001; 5%-10% v 0.1-10% p<0.001).

      Conclusion
      Lung cancer clinicians judged moderate survival benefits sufficient to make ACT in NSCLC worthwhile, but preferences differed according to specialty. Clinicians’ preferences were similar to patients’ preferences, but varied less. Lung cancer clinicians should be mindful of their own preferences and how they may influence discussions and decisions about ACT in NSCLC.

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      P1.12-011 - Patients' preferences for adjuvant chemotherapy (ACT) in early non-small cell lung cancer (NSCLC): What makes it worthwhile? (ID 1773)

      09:30 - 09:30  |  Author(s): N. Muljadi

      • Abstract

      Background
      ACT for NSCLC improves overall survival, but the benefits are modest and must be weighed against the harms and inconvenience of the treatment. The aim of this study was to determine the survival benefits judged necessary to make ACT worthwhile for patients with resected early NSCLC, and the factors associated with their judgments.

      Methods
      122 patients considering ACT completed a self-administered questionnaire at baseline (before ACT, if they were having it) and 6 months later (after ACT, if they had it). The time trade-off method was used to determine the minimum survival benefits judged sufficient to make ACT worthwhile in 4 hypothetical scenarios. Baseline survival times were 3 and 5 years and baseline survival rates (at 5 years) were 50% and 65%. All tests were 2-sided and non-parametric. Determinants of preferences were assessed by (rank test) comparison of preferences in groups defined by each factor.

      Results
      Most patients were male (57%) with a median age of 63 years (range, 43-79 years), married (72%) and previous smokers (81%). The majority had had a lobectomy (84%), adenocarcinoma histology (60%), and half had stage II disease (50%). 106 patients decided to have ACT (87%), 16 declined ACT (13%); female sex and age over 65 years were associated with declining. ACT was most commonly 4 cycles (68%) of cisplatin/ vinorelbine (73%). At baseline, the median benefit judged sufficient (by 50% of patients) was 9 months (IQR 1-12 months) beyond life expectancies of 3 years and 5 years, and 5% (IQR 0.1-10%) beyond 5-year survival rates of 50% and 65%. Preferences varied across the entire range of possible benefits (from 0 days and 0% to an extra 15 years and 50%). At baseline, deciding to have ACT (p=0.01) was the only factor that predicted judging smaller benefits sufficient to make ACT worthwhile. At 6 months (n=91), the median benefits judged sufficient were the same as at baseline (9 months & 5%), but preferences varied over a greater range (IQR’s 0-18 months & 0-15%). At 6 months, deciding to have ACT (p=0.02) and better physical (p=0.02), emotional (p=0.004), and overall well-being (p=0.004) during adjuvant chemotherapy were associated with judging smaller benefits sufficient to make ACT worthwhile. Fatigue, nausea, sleeplessness and reduced appetite were the side effects of ACT that patients were most concerned about experiencing (at baseline) and were rated the most troublesome (at 6 months).

      Conclusion
      Most patients judged moderate survival benefits sufficient to make ACT worthwhile, but preferences varied widely and were not predicted by baseline characteristics. Preferences were stable over time. Patients with NSCLC judged larger benefits necessary for ACT than patients with breast and colon cancer in our previous studies. Clinicians should elicit the preferences of individual patients when discussing and making decisions about ACT.

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    P2.10 - Poster Session 2 - Chemotherapy (ID 207)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P2.10-040 - Prognostic significance, accuracy and usefulness of oncologists' estimates of survival time for patients starting first-line chemotherapy for advanced non-small-cell lung cancer (ANSCLC) (ID 2560)

      09:30 - 09:30  |  Author(s): N. Muljadi

      • Abstract

      Background
      Oncologists are frequently required to provide estimates of survival time for their patients with advanced cancer. The aims of this study were to determine the accuracy and prognostic significance of oncologists’ estimates of survival time above and beyond conventional prognostic factors.

      Methods
      Medical oncologists from 26 sites in Australia and New Zealand recorded the “expected survival time in months” for individual patients with ANSCLC prior to randomisation in a trial of first-line chemotherapy with a platinum-based doublet. Blood samples, demographics, tumour and treatment characteristics were collected at baseline along with the oncologist’s rating of each patient using Spitzer’s Quality of Life Index (SQLI). Based on previous studies, we deemed estimates within 0.75-1.33 times observed survival as precise, and expected 50% of patients to live longer (or shorter) than their oncologist’s estimate, 50% to live from half to double their oncologist’s estimate (typical scenario); 5-10% to live ≤¼ of their estimate (worst-case scenario); and, 5-10% to live ≥3 times their estimate (best-case scenario). Associations between estimated and observed survival times in months were assessed with Cox proportional hazards regression before and after adjustment for baseline prognostic factors including age, gender, Eastern Cooperative Oncology Group performance status (ECOG PS), cancer extent, histology, co-morbidities, laboratory results and SQLI.

      Results
      Estimates of survival were available for 244 (98%) of the first 250 patients randomised. Patient characteristics were: median age 64 years; female 40%; adenocarcinoma 64%; ECOG PS 0-1 92%; and distant metastases 71%. After a median follow-up of 21 months there were 172 deaths (69%). The median (interquartile range, IQR) for observed survival was 10 months (5-20) and for estimated survival was 11 months (9-12). Oncologists’ estimates were imprecise (22% from 0.75-1.33 times observed) but well calibrated (47% of patients lived shorter than expected and 53% lived longer than expected). The proportions of patients with observed survival times falling within ranges bounded by simple multiples of their estimated survival times corresponded closely with our a-priori hypotheses: 10% lived ≤1/4 of their estimated survival time, 53% lived from half to double their estimated survival time, and 13% lived ≥3 times their estimated survival time. The oncologist’s estimate of survival time at baseline was the strongest predictor of observed survival in both univariable analysis (HR 0.90, 95% CI 0.86-0.95, p<0.001) and multivariable analysis (HR 0.90, 95% CI 0.86-0.95, p<0.001) accounting for all other independently significant predictors, namely: estimated neutrophil-lymphocyte ratio >5 (HR 3.15, 95% CI 1.76-5.64, p<0.001); haemoglobin <120g/L (HR 1.93, 95% CI 1.3-2.9, p=0.001) and total white cell count >11x10[9]/L (HR 1.55, 95% CI 1.05-2.27, p=0.03).

      Conclusion
      Oncologists' estimates of survival time were independently associated with observed survival time and provided a reasonable basis for estimating worst-case, typical and best-case scenarios for survival. Oncologists’ estimates provide useful additional prognostic information, above and beyond that provided by established prognostic factors.