Health Utility and Symptom Scores in Patients With Advanced Malignant Pleural Mesothelioma Treated in a Real-World Setting

Our plain-English summary of Health Utility and Symptom Scores in Patients With Advanced Malignant Pleural Mesothelioma Treated in a Real-World Setting, by A. Mittal, L. Everest, D. Patel, et al (JTO Clinical and Research Reports, 2025).

The study

• Authors: A. Mittal, L. Everest, D. Patel, L.J. Zhan, M.C. Brown, F. Zaeimi, S. Schmid, K. Khan, K. Dietrich, K. Balaratnam, M.G.P. de Santayana, L. Eng, A.G. Sacher, F.A. Shepherd, N.B. Leighl, J. Cho, M. De Perrot, G. Liu, P. Bradbury
• Journal: JTO Clinical and Research Reports
• Published: 2025;6(6):100802
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: There is a paucity of real-world associations between EQ-5D-generated health utility scores (HUS), symptoms as measured by the Edmonton Symptom Assessment System (ESAS), and the patient-reported outcomes version of the common terminology criteria for adverse events (pro-CTCAE), and survival in patients with advanced Malignant Pleural Mesothelioma (aMPM).

Methods: Clinico-demographic variables and treatment information were captured retrospectively in patients diagnosed with aMPM between January 2004 and February 2021 at Princess Margaret Cancer Centre. Quality of life outcomes were measured using HUS, ESAS, and pro-CTCAE scales, by stable versus progressive disease and line-of-treatment states. Survival by mean ESAS scores were analyzed using the Kaplan-Meier method.

Results: Of the 262 patients, the median age was 69 years (interquartile range: 62-74), 77% were male individuals, 52% were ever-smokers, 67% were the epithelioid-subtype, and 62% received first-line systemic therapy for advanced disease. The mean baseline HUS at diagnosis was 0.68 (95% confidence interval: 0.62-0.74) with most symptoms consisting of pain, dyspnea, and fatigue. Pooled ESAS physical and psychological scores changed significantly with disease state: the mean scores were worst at baseline, improved with stable or responding disease (physical, p < 0.001; psychological, p < 0.001), and worsened at progressive disease (physical: p < 0.001; psychological, p < 0.001). Similar trends were seen in HUS and pro-CTCAE symptom severity/frequency. Patients with high baseline ESAS physical symptom burden had inferior overall survival (median = 8.9 [high] versus 12.6 months [low], p = 0.022). Weak-to-moderate correlations were observed between most ESAS domains and HU and between pro-CTCAE domains and HU. The strongest domain correlations were with well-being, shortness of breath, tiredness, and depression domains.

Conclusions: Baseline quality of life burden is high in patients with aMPM and is well captured by both EQ-5D and ESAS Individual ESAS and pro-CTCAE domains reported low/moderate correlations with HUS, reflecting the inability of one symptom to predict the entire disease state, thus paving the way for future mapping studies. The baseline physical symptom burden (ESAS) was prognostic of survival.

© 2025 by the International Association for the Study of Lung Cancer.

In plain English

This single-centre retrospective study examined quality of life in 262 patients with advanced malignant pleural mesothelioma diagnosed from January 2004 to February 2021 at Princess Margaret Cancer Centre, Toronto. It used three patient questionnaires: the EQ-5D health utility score (1 is the best possible health), the Edmonton Symptom Assessment System (ESAS, 0 best to 10 worst), and the pro-CTCAE. Of the patients, 54% reported past asbestos exposure. Among 49 patients with a baseline EQ-5D score, the median was 0.68 (95% CI: 0.62–0.74). In ESAS data from 247 patients, pooled physical and psychological scores improved with stable disease and worsened with progression. Patients whose average baseline physical symptom score was 4 or higher had a median overall survival of 8.9 months (95% CI: 6.6–12.1). Those below 4 had a median of 12.6 months (95% CI: 11.9–14.9), p = 0.022. Individual symptoms showed only low to moderate correlation with the health utility score. The authors concluded that symptom burden at diagnosis was high and that baseline physical symptom burden was prognostic of survival. They called the follow-up analyses exploratory because few patients contributed data at every stage.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Single-institution retrospective cohort study of patient-reported quality of life and survival
• Who was studied: 262 patients with advanced malignant pleural mesothelioma and any quality-of-life data, diagnosed January 1, 2004 to February 1, 2021, at University Health Network Princess Margaret Cancer Centre, Toronto. Median age was 69 years, 77% were male and 67% had the epithelioid subtype.
• Exposure: Asbestos was not the main exposure studied. The study examined symptom and quality-of-life burden, measured by EQ-5D health utility scores, ESAS and pro-CTCAE, across disease states (baseline, stable or responding disease, progressive disease) and lines of treatment. Self-reported asbestos exposure was 140 (54%) exposed, 64 (25%) not exposed and 56 (22%) unsure.
• Main results:
  • EQ-5D data were available for 117 patients. Among the 49 with a baseline score, the median baseline health utility score was 0.68 (95% CI: 0.62–0.74).
  • In the mixed-effects model, mean health utility was 0.70 (0.64–0.76) at baseline, 0.67 (0.62–0.73) with stable disease and 0.61 (0.56–0.65) with progressive disease. The change by disease state had p = 0.01.
  • ESAS data were available for 247 patients. Mean pooled physical ESAS scores were 3.17 at baseline, 3.03 with stable disease and 3.50 with progressive disease. Mean pooled psychological scores were 3.24, 2.76 and 3.33. Table 2 gives p less than 0.001 for both.
  • Patients with a high baseline ESAS physical burden (mean score 4 or higher) had a median overall survival of 8.9 months (95% CI: 6.6–12.1). Patients with a low burden had a median of 12.6 months (95% CI: 11.9–14.9), p = 0.022.
  • Median first-line progression-free survival was 5.7 months (95% CI: 4.1–7.1) with high ESAS physical burden and 8.6 months (95% CI: 7.1–10.0) with low burden, p = 0.001.
  • Overall survival was not significantly different by pooled ESAS psychological score (p = 0.79) or by ESAS well-being score (p = 0.33).
  • All ESAS domains were significantly associated with the EQ-5D health utility score, but correlations were generally low to moderate. The strongest were for well-being, shortness of breath, tiredness and depression.
  • Patients with lower ESAS physical burden generally had a lower proportion of missing data than patients with higher physical burden.
• The authors' conclusion: The authors concluded that baseline symptom burden was high and contributed to poor health utility at diagnosis of advanced disease. They concluded that physical symptom burden on ESAS was prognostic for survival. They also concluded that no single ESAS symptom fully predicted health utility, so measuring both may give a more complete picture of quality of life.
• Limitations the authors state:
  • The study was single-institution and retrospective, with relatively few patients contributing baseline data for all three scales.
  • Because of attrition and deaths, few patients contributed data for all scales in all disease states. The authors described the follow-up changes and correlations as exploratory and hypothesis-generating.
  • Some patients had only EQ-5D-3L scores. These were converted to EQ-5D-5L using U.S. preference weights because Canadian weights were not available, which the authors said may introduce uncertainty.
  • Some patients refused to participate, and the extent of participation bias could not be determined.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Quality of Life, Epithelioid, Systemic Therapy, confidence interval, Dyspnea, Overall Survival.

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