There is a clear need to understand the impact of lung cancer treatment on patients’ expectations and the consequences to their everyday lives, which are often bound to those of their careers and their families. This need is commonly brought to our attention in the clinic when we are asked “doctor, what would you do?” but also by increasing patient awareness of the impact of treatment on their quality, as well as quantity, of life.
To answer these specific questions, we, as lung cancer physicians, need to pay more attention to the entire journey of our patients, especially in the era of multi-modality treatment planning.
In our research, we have asked patients directly if collecting quality-of-life information posed an additional burden during their cancer journey. We showed in a qualitative study1 that patients felt more, rather than less, reassured when questioned about their quality of life and the daily impact of cancer had on their working and social lives. These patient-clinician conversations have also provided patients with an in-depth awareness of both post-surgical and/or post-radiotherapy side effects.
Respondents reported visits with their providers could have been more focused and time could have been saved for themselves and their clinicians had pertinent quality-of-life questions been asked early in the treatment process.1
There is a key psychological component when patients and families face a lung cancer diagnosis. Clinicians need to be aware of the effects this can have on the subsequent decision-making process. In addition, other factors, especially the cultural and ethnic background of a patient and family, need to be considered.
Life after Lung Cancer (Lilac) is a prospective observational longitudinal study using repeated Quality of Life (QoL) measures for one year after treatment.1 Patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) or Stereotactic Ablative Radiotherapy (SABR) for early-stage NSCLC were consecutively recruited from the Leeds Teaching Hospitals NHS Trust, UK.
QoL data were collected using the European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire (QLQ-C30) and its Lung Cancer specific Module (LC13) at baseline and 6 weeks, and then at 3, 6, and 12 months post-treatment through an online platform, which was linked to the electronic patient record.2
The Lilac study enrolled 244 patients. As expected, the two groups differed considerably in their clinical pre-treatment features. SABR patients were older than the surgical group [mean age (SD) 74.3 (9.20) and 70.0 (8.84) respectively]; had significantly worse respiratory parameters; poorer performance status (57% had Eastern Cooperative Oncology Group (ECOG) Performance Score > 1 vs 16% of VATS patients), and more co-morbidities.
SABR patients were more compliant with baseline completion of QoL questionnaires (78%) versus only 54% compliance by VATS patients. This may reflect the increased time available during the SABR planning process, which allowed patients to complete the questionnaires, and it highlights the need to support patients better in the pre-operative period.
The Enhanced Recovery After Surgery program at Leeds, aims to ready patients for surgery using a patient-centered approach. However, we need to be conscious that following a cancer diagnosis, the same education and information can be dealt with and processed differently by each patient. The addition burden of being included in a research study during the limited key time before surgery may explain why the Lilac study was not a priority for some patients, and it may explain the lower response rate during the early period compared to SABR patients.
The patient-reported results showed that SABR patients maintained overall stability during the 12 months across all functions and symptoms. At the post-treatment time point of 6 weeks, used to evaluate potential toxicity from SABR, a slight deterioration was seen in role function, dyspnoea, and cough. Those parameters returned to pre-treatment values by 3 months. General pain showed a trend for late worsening between 3 and 12 months, only emotional function improved from baseline to 3 months by a clinically meaningful amount. QLQ-C30 summary score, a composite measure of functioning and symptomatology, remained stable during all time points.
Surgical patients, who had relatively good function and fewer symptoms at baseline, reported clinically significant deterioration at 6 weeks, the first time point after the surgery. Most deterioration was seen in role, physical, and social functions, global health, as well as physical symptoms, including fatigue, dyspnea, pain, appetite loss, constipation, and pain in chest and arms.
However, we do not have data to know if patients were receiving radiotherapy or chemotherapy postoperatively, which could be confounding factors.
In the subsequent reports at 3, 6 and 12 months, the core measures improved (suggesting a recovery from postoperative problems), but without regaining baseline levels. Role function, pain, C30 dyspnoea, and LC13 alopecia remained lower than baseline by a clinically meaningful amount. The composite measure of QLQ-C30 summary score, showed clinically meaningful deterioration at 6 weeks, with improvement afterwards, but without reaching baseline scores.
Dyspnoea and fatigue are two symptoms that at 6 weeks increased more in surgical patients compared to SABR patients. Intriguingly, patient-reported dyspnoea improved at 6 months in both groups. However, in SABR patients it returned to lower than baseline level while it remained higher than baseline in surgical patients. This supports the acute effect of a surgical resection on patients’ respiratory function.
Early post-treatment QoL scores indicate that SABR is a well-tolerated treatment for patients with early-stage NSCLC. Surgery had a greater impact on patient-reported symptomatology and the ability of these patients to comply with our research protocol. When considering the adoption of enhanced recovery plans for surgical patients, we need to take into consideration that our patients need more support and more time to process the information, and understand the time required to regain their emotional and physical functioning.
The Lilac study demonstrated that QoL collection is feasible, and other studies,3,4 support the use of electronic remote symptoms reporting as a practical solution for integrating it into Enhanced Recovery After Surgery programs.
- 1. Pompili C, Boele F, Absolom K, et al. Patients’ views of routine quality of life assessment following a diagnosis of early-stage non-small cell lung cancer. Interact Cardiovasc Thorac Surg. 2020;31(3):324-330. doi:10.1093/icvts/ivaa123
- 2. Koller M, Shamieh O, Hjermstad MJ, Hornslien K, Young T, Chalk T et al. Psychometric properties of the updated EORTC module for assessing quality of life in patients with lung cancer (QLQ-LC29): an international, observational field study. The Lancet Oncology 2020.
- 3. Dai W, Feng W, Zhang Y, Wang XS, Liu Y, Pompili C et al. Patient-Reported Outcome-Based Symptom Management Versus Usual Care After Lung Cancer Surgery: A Multicenter Randomized Controlled Trial. Journal of Clinical Oncology;0:JCO.21.01344.
- 4. Absolom K, Warrington L, Hudson E, Hewison J, Morris C, Holch P et al. Phase III Randomized Controlled Trial of eRAPID: eHealth Intervention During Chemotherapy. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2021;39:734-47.