Prognostic Significance of Patient-Reported Outcomes in Cancer

Kathleen Kerrigan, DO; Shiven B. Patel, MD; Benjamin Haaland, PhD; Dominik Ose, PhD; Anna Weinberg Chalmers, MD; Tyler Haydell, BS; Neal J. Meropol, MD; Wallace Akerley, MD

Disclosures

J Oncol Pract. 2020;16(4):e313-e323. 

In This Article

Abstract and Introduction

Abstract

Purpose: Performance status (PS), an established prognostic surrogate of cancer survival, is a physician-synthesized metric of patient symptoms and mobility that is prone to bias and subjectivity. The National Cancer Institute (NCI) Patient-Reported Outcomes Measurement Information System–Cancer (PROMIS-Ca) Bank, a patient-centric patient-reported outcome (PRO) evaluation of physical function (PF), fatigue, depression, anxiety, and pain, shares subject matter with PS and, therefore, may also be prognostic while eliminating physician interpretation.

Methods: Patients at Huntsman Cancer Institute were assessed using the NCI PROMIS-Ca Bank. Using tablets at routine office visits, PF, fatigue, depression, anxiety, and pain scores were collected from patients with advanced melanoma, non–small-cell lung cancer, colorectal cancer, and breast cancer. A PRO score collected at a single time point within 6 months of metastatic diagnosis for each patient was merged with curated clinical outcome data. The association of PROs, overall survival (OS), and hospitalization-free survival (HFS) were assessed in multivariable analysis that included sex and cancer type.

Results: Two hundred eighty-two complete sets of patient data were available for analysis. All 5 PRO domains were strongly prognostic of OS and HFS. While the PRO domains were interrelated with moderate to strong correlations (0.40–0.79), multivariable regression suggested that PF was most strongly associated with the clinical outcomes of OS (P < .001) and HFS (P < .001).

Conclusion: NCI PROMIS-Ca PROs may be prognostic of both cancer survival and likelihood of hospitalization. Future prospective studies are needed for all major prognostic factors to fully understand the independent prognostic value of PROs.

Introduction

Karnofsky and Eastern Cooperative Oncology Group performance statuses (PSs)[1,2] are subjective, physician-synthesized compilations of patients' symptoms, physical and self-care ability, and symptom burden. PS is believed to reflect physiologic reserve and tumor burden and is used to make decisions about cancer treatment, eligibility in clinical trials, and estimations of prognosis. PS is subject to bias by physicians, patients, and caregivers and may not be truly reflective of how well a patient is doing at any given time point. Previous studies have demonstrated significant interobserver variability in the measurement of PS, with health professionals, including oncologists and nurses, assigning greater PS scores than patients with cancer at the same time points.[3,4] Patients with advanced cancer typically experience a period of preserved PS during the initial management of their disease followed by decompensation, increased symptom burden, and frequent hospitalization. Data from a Medicare analysis in 2012 demonstrated that 65% of patients with advanced cancer were hospitalized within 30 days of their death, and 25% of these patients required intensive care unit level of care.[5] In addition, analyses have shown that up to 50% of patients with advanced cancer receive cancer-directed therapy within 30 days of their death[6] and that it is often of limited survival benefit and at a substantial cost.[7] This creates a significant financial burden for our health care system. More importantly, it negatively affects patients' quality of life because those who receive chemotherapy at the end of life are less likely to receive the benefits and appropriate duration of hospice care.[8]

Patient self-reported health measures are potentially more accurate reflections of an individual's physical functioning and emotional well-being because these are not subject to physician interpretation and bias.[4] In other studies, the use of patient-reported outcomes (PROs) in the clinic has demonstrated improved physician-patient communication, symptom awareness and management, and patient quality of life.[9–11] Furthermore, implementation of PROs into academic oncology practice has been shown to reduce the number of emergency department visits and hospitalizations, prolong patient tolerability of chemotherapy, and improve overall survival (OS).[12–14]

In 2004, the National Institutes of Health developed the Patient-Reported Outcomes Measurement Information System (PROMIS) to validate PROs for use in both clinical oncology practice and clinical research. Our study examines the relationship between OS and hospitalization-free survival (HFS) and 5 PROMIS domain measures among patients with metastatic cancer in an academic oncology setting.[15]

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