Considering Treatment Preferences for Advanced Lung Cancer Patients

A new study from BMC Cancer showed patients with advanced non­­­­–small-cell lung cancer (NSCLC) had preferences as to which chemotherapy-related side effects they would prefer to avoid, emphasizing the importance of asking patients about their treatment preferences and highlighting the feasibility of practicing patient-centered care.

The prospective cohort study included 235 advanced-stage NSCLC patients from nine cancer center sites, most of which were in the United States. Medical records were analyzed to collect patient data. Interviews or questionnaires were conducted before, during, and/or after chemotherapy treatment in the first-line setting to gather information about each patient’s treatment preferences. All patients completed at least one interview and the majority (71%) completed at least two.

In the surveys, patients were asked how long they were willing to tolerate side effects and which side effects they would prefer to avoid. The study assessed whether these preferences changed over time.  To determine whether this information could inform treatment decisions, patient side effect preferences were compared to the side effect profiles of four chemotherapy drugs commonly used in the first-line setting for advanced NSCLC.

The study revealed that before receiving chemotherapy, a similar proportion of patients reported they could tolerate side effects from chemotherapy for “months” (41%) vs “years” (43%). However, later on as patients were exposed to chemotherapy, the proportion of patients who could tolerate side effects for a shorter period of time (ie, months) increased to half of patients.

Patients reported the same three side effects that they would prefer to avoid, but the rank differed over time. Before treatment, shortness of breath was ranked highest, followed by bleeding and fatigue; later on, fatigue was ranked highest, followed by shortness of breath, and bleeding.

“The finding that patients are more concerned about fatigue after starting chemotherapy is interesting and suggests that symptom management of this and all symptoms is very important,” said Laura Petrillo, MD, palliative care physician at Massachusetts General Hospital, Boston, and instructor of medicine, Harvard Medical School, during an interview with Cancer Network.

The study also showed side effect preferences could identify which of the four chemotherapy drugs could be avoided. For instance, based on the patient’s side effect ranking before receiving chemotherapy, 42.5% of patients would have wanted to avoid Drug B. Later on, 49.4% would have wanted to avoid Drug B.

 “My impression is that the authors are recommending that doctors elicit patient preferences about side effects on a case-by-case basis,” Petrillo said about how the findings can be applied in everyday practice.

While the study examines one potential aspect of decision-making about chemotherapy for lung cancer, Petrillo points out that it’s important to ask what barriers prevent shared decision-making and incorporation of patient preferences when it comes to making decisions related to cancer care.

“It is not clear that facilitating elicitation of patient side effects using a ranking system is sufficient,” Petrillo said. “Doctors need to choose to incorporate such elicitation into their practice and invite patients into the decision-making process, or patients need to be educated to advocate for themselves to have their preferences included, or both, to achieve patient-centered care....Moreover, there are many values that are important besides side effects, and how to fit other patient values and integrate evidence about drug efficacy, when all options are not equal, is complex.”