Time trends in opioid use in cancer and noncancer patients: Observations from administrative data

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Background: Opioid prescribing has been increasingly scrutinized in the non-cancer patient population due to concerns with morbidity, mortality and diversion. Resulting regulatory changes have decreased prescribing. As an unintended consequence, we hypothesized that cancer patients might be similarly impacted. Methods: All Ontario residents ≥ 65 years are eligible for government paid pharmacare. For each year from 2004 to 2013, Ontarians ≥ 65 years were stratified into 3 groups: no cancer history, cancer diagnosis > 5 years ago and cancer diagnosis ≤ 5 years ago. We evaluated time trends in 2 outcomes: (1) opioid prescription rate = total number of pharmacare claims / total population of ≥ 65 year olds, and (2) mean daily opioid dose (in morphine equivalents) = sum of all patient’s mean daily opioid doses over their first 90 days of opioid therapy in each year / total patients with an opioid prescription in that year. Results: Ontario’s population of ≥ 65 year olds increased each year with 2.1 million residents in 2013 (5% recent cancer, 10% remote cancer). Demographics were similar by year for each group. Across all years, overall opioid prescription rates were highest for those with a recent cancer and lowest for those with no cancer history. Overall prescription rates increased over time by 23%, 14% and 10% in the non-cancer, remote cancer and recent cancer groups respectively, primarily due to increases in long acting opioids and immediate release single agents. Decreases were seen in long acting oxycodone and fentanyl prescriptions in all cancer groups. The mean daily opioid dose increased for patients receiving long acting oxycodone and fentanyl but was relatively stable for other drug classes. With the exception of immediate release single agents, the mean daily dose was similar between cancer groups regardless of drug class. Conclusions: Regulatory measures have succeeded in decreasing prescription rates in some but not all drug classes among Ontarians aged ≥ 65. Changes over time in both prescription rates and mean daily opioid dose were similar for all 3 groups, suggesting that factors influencing prescribing are affecting cancer and non-cancer patients similarly, possibly to the detriment of some cancer patients.

Ontario’s approach to tackling drug funding sustainability

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Background: One of the challenges facing Ontario relates to managing the rising costs of cancer drug treatments. The annual growth rate of cancer drug spending has increased by 10-20% since 2010, exceeding other therapeutic categories and is expected to continue to grow significantly faster than expenditures in other areas. Paradoxically, the price of a drug seems to have little relation to its demonstrated efficacy ( http://www.asco.org/practice-research/cancer-care-america-2015/focus-cost ). The Cancer Quality Council of Ontario (CQCO) and Cancer Care Ontario (CCO) embarked on a journey to systematically address this challenge. Methods: The CQCO and CCO focused on identifying and reviewing the critical success factors of a sustainable drug reimbursement program with international, pan-Canadian and internal input. Recognizing that drug funding sustainability is a challenge faced by health systems worldwide, the scope of this work was broadened from a provincial focus to one that was relevant across the Canadian context. Results: Ultimately, this work resulted in CQCO providing a core set of recommendations for CCO that may also be relevant to other reimbursement programs, in order to maximize the effectiveness of cancer drug use and support overall system sustainability in a patient-centred way. The recommendations to address drug funding sustainability included: (1) Transparency in drug funding decisions; (2) development of process to incorporate current best evidence to support system sustainability; (3) development of a consistent approach to gathering and analyzing real world evidence (RWE); (4) development of a consistent process for disinvestment and renegotiation of prices with buy-in from public, patients and clinicians; (5) development of a provincial process to maximize harmonization in cancer drug funding coverage decisions; (6) refinement of the algorithm and priority setting for review of drug submissions; and (7) incorporating RWE into funding decisions and downstream re-evaluation. Conclusions: CCO is determining an action plan based on the above recommendations and developing partnerships to support successful implementation to improve sustainability in regards to cancer drug funding.

The impact of immigration status on cancer outcomes in Ontario, Canada

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Background: In the delivery of cancer care, barriers to access could potentially result in inferior outcomes and survival. Although a relationship has been demonstrated between disadvantaged socio-economic status and mortality, the impact of immigration on outcomes is less clear. Methods: Administrative databases were linked to create a cohort of all incident cases of colorectal, lung, prostate, head/neck, breast and hematologic malignancies from Jan 2000 to Dec 2012 in Ontario, Canada. Cases were defined according to immigration status and followed from diagnosis until death (or cancer-specific death). Cox proportional hazards models were constructed to study the impact of immigration status on survival after adjusting for relevant variables. Additional adjusted models studied the relationship of time since immigration on mortality. Results: During the study period, 11,485 cancer cases were diagnosed in recent immigrants (0-10 years in Canada), 17,844 cases in non-recent immigrants (11-25 years), and 416,118 cases in non-immigrants. Following adjustment for relevant predictors by Cox regression, survival was improved for recent immigrants (HR 0.843; 95% CI 0.814-0.873) and non-recent immigrants (HR 0.902; 95% CI 0.876-0.928) compared to non-immigrants. Cancer-specific survival was also better for recent immigrants (HR 0.857; 95% CI 0.823-0.893) and non-recent immigrants (HR 0.907; 95% CI 0.875-0.94) compared to non-immigrants. Amongst immigrants, each year from the original landing in Canada was associated with increased mortality (HR 1.004; 1.000-1.009) and a trend to increased cancer-specific mortality (HR 1.005; 0.999-1.010) that was not statistically significant. Immigrants from all WHO world regions were found to have similar reductions in mortality and cancer-specific mortality. Conclusions: Immigrants to Canada demonstrate a “healthy immigrant” effect, with lower mortality compared to Canadian-born individuals. This benefit appears to diminish over time, as the health of immigrants potentially converges with the Canadian norm. Potential contributors to the benefit include self-selection for immigration, health requirements for entrance, and differences in disease distribution related to ethnicity.

Systemic treatment patterns in small bowel and appendiceal adenocarcinomas (SBA and AA): A population-based study

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Background: There is uncertainty regarding the optimal systemic treatment for patients with SBA and AA due to the limited available evidence for these uncommon malignancies and conflicting recommendations in existing guidelines. However, on the basis of biologic similarities between SBA, AA and colorectal cancer (CRC), common practice is to use the same systemic therapies as for CRC. We compared the utilization of chemotherapeutic agents for SBA and AA to that of CRC patients in Ontario, Canada. Methods: The provincial tumour registry in Ontario, Canada was used to identify patients diagnosed with SBA, AA or CRC from 2010-2014. Subsequent chemotherapy utilization and costs were captured from single-payer government administrative databases. We studied the use of oxaliplatin, irinotecan, capecitabine, bevacizumab, cetuximab, panitumumab, and raltitrexed, which are funded for CRC treatment. Patients were excluded if they had multiple primary cancer sites, morphology codes inconsistent with adenocarcinomas, or missing identification data. Statistical analyses were used to report and test patterns of utilization and average costs per patient. Results: Our cohort consisted of 30,946 patients over a 5-year period. On average, 160 and 80 patients were diagnosed annually in Ontario with SBA and AA, respectively, together representing less than 4% of the total diagnoses each year. Among SBA and AA patients, 30-40% initiated therapy with the selected systemic therapies, similar to the proportion in CRC. SBA and AA patients were less likely to receive adjuvant oxaliplatin (SBA 9%, AA 13%) compared to CRC (18%) patients, but more likely to use first and second-line oxaliplatin or irinotecan for metastatic disease. Bevacizumab was added to first-line therapy for SBA and AA patients in fewer cases than CRC (SBA 29%, 45% AA, 72% CRC). Third-line EGFR inhibitors panitumumab and cetuximab were used infrequently in all groups ( < 2% of those diagnosed). Average per patient costs were similar across disease sites (p > 0.05). Conclusions: On a population level, SBA and AA patients appear to be managed similarly to CRC patients and at similar cost. Future research will evaluate survival outcomes.

Does the dose of leucovorin (LV) matter with 5-fluorouracil (5FU) in colorectal cancer (CRC)?

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Background: In June 2015 Cancer Care Ontario convened an expert panel to determine if there is an optimum LV dose in 5FU-LV combinations for the treatment of CRC. This request arose out of observed variation in LV dosages between some cancer centers. The research question was effect of LV dose on overall survival (OS), progression free survival (PFS), disease free survival (DFS), response rate (RR) and adverse events/toxicity, given a constant dose of 5FU. Methods: A systematic search was conducted for guidelines (GL) and comparative trials; eligibility included English language, with > 30 patients, that examined different doses of LV where dose of 5FU was not varied. Assessment of studies for inclusion was completed by 4 reviewers. Results: We identified 5 GL, 0 systematic reviews and 12 trials that defined a LV dose in combination with 5FU. None of the GL informed an optimal dose of LV. RR was assessed in 10 trials; 4 showed trends to higher RR with higher LV dose, but differences were not statistically significant (SS) between arms. PFS or DFS was reported in 6 trials and was similar between arms. Time to recurrence reported in one trial that included bevacizumab (BV) was longer in the high dose LV group that was SS. OS was addressed in 10 studies: no difference found in 7 studies; in one RCT OS was longer with the higher dose LV 55 vs. 45 months (p not reported); in one retrospective study OS was 23 vs. 20 months in favor of high dose LV (p not reported); one study of LV and BV had longer OS vs. lower dose LV at 26 vs. 21 months (SS). Toxicity: higher dose LV was associated with greater toxicity in 3 of 4 studies that reported stomatis, and increased rates of diarrhea in 9 of 11 trials. Meta-analysis was not appropriate as studies were too heterogeneous. Conclusions: There is no convincing evidence to identify an optimum dose of LV to be used in 5-FU/LV combinations. Amongst studies that did show a difference the trend was improved survival in favor of the higher dose. Similarly, differences in toxicities when identified were consistently greater with the higher dose LV. The expert panel concludes that the existing literature provides insufficient data to suggest that chemotherapy protocols should deviate from standard protocol doses.

Association of hospital and physician case volumes with cardiac monitoring and cardiotoxicity during adjuvant trastuzumab treatment for breast cancer: a retrospective cohort study

BACKGROUND

Adjuvant trastuzumab is the standard of care for patients with HER2 overexpressing breast cancer, but use of trastuzumab may lead to cardiotoxicity. Our goal was to evaluate the relationship between hospital and physician case volume and cardiac outcomes in this population.

METHODS

In this retrospective cohort study, we identified all female patients in Ontario with a breast cancer diagnosis in 2003-2009 who underwent treatment with trastuzumab through a provincial drug-funding program and linked these patients to administrative databases to ascertain patient demographics, treating hospital and physician characteristics, admissions to hospital, cardiac risk factors, cardiac imaging and comorbidities. Insufficient cardiac monitoring was defined as per the Canadian Trastuzumab Working Group guideline. Cardiotoxicity was defined as receiving fewer than 16 of 18 doses of trastuzumab because of heart failure admission, heart failure diagnosis or discontinuation of the drug after cardiac imaging. We constructed hierarchical multivariable logistic regression models to evaluate the effect of annual hospital volume, cumulative physician volume and treatment period on cardiac monitoring and cardiotoxicity.

RESULTS

Of 3777 women treated by 214 oncologists at 68 hospitals, 918 (24.3%) had insufficient cardiac monitoring and cardiotoxicity developed in 640 (16.9%). Cardiotoxicity occurred in 389 (42.4%) and 251 (8.8%) patients in the insufficient- and sufficient-monitoring groups, respectively. Higher annual hospital and cumulative physician volumes, and more recent calendar period, were all independent predictors for decreased cardiotoxicity. Adjustment for rates of cardiac monitoring annulled the relationships between case volume and cardiotoxicity.

INTERPRETATION

Greater hospital and physician case volumes are associated with reduced rates of trastuzumab-related cardiotoxicity, most likely because of better cardiac monitoring at higher volume centres.

Timeliness of end-of-life (EOL) discussions for blood cancers: A national survey of hematologic oncologists

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Background: Although timely EOL discussions have been shown to positively impact EOL care for patients with advanced solid tumors, little is known about EOL discussions for patients with blood cancers. Methods: In 2014, we mailed a 30-item survey to a national sample of hematologic oncologists randomly selected from the American Society of Hematology clinical directory. The survey was developed through focus groups (n=20) and cognitive debriefing (n=5) with hematologic oncologists. We report preliminary data regarding timing of EOL discussions. Results: We received 349 surveys from 48 states (response rate: 57.3%). Median age was 52 years, median time in practice was 25 years, and 43% practiced primarily in tertiary centers. Of all respondents, 56% reported that EOL discussions with blood cancer patients typically occur “too late.” The great majority also reported conducting initialdiscussions regarding resuscitation status, desire for hospice care, and preferred site of death at times other than periods of disease stability (Table). In multivariable analysis adjusting for gender, years in practice, and self-reported confidence leading EOL discussions, respondents practicing in tertiary centers were more likely to report that such discussions occur “too late” (OR=1.91, 95% CI [1.22, 2.98]). Similarly, hematologic oncologists practicing in tertiary centers were less likely to report conducting timely initial resuscitation status discussions (before acute hospitalization or before death clearly imminent, OR=0.52, 95% CI [0.33, 0.82]). Conclusions: The majority of hematologic oncologists in our large national cohort reported late EOL discussions. Moreover, clinicians in tertiary centers were more likely to report late discussions, even when prompted about specific EOL topics. Our data suggest that physician-focused interventions to improve timing of EOL discussions for blood cancers should target those practicing in tertiary centers. [Table: see text]

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care

Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to participate in a targeted conversation about the appropriateness and quality of individual patient care.

Population-Based Assessment of Emergency Room Visits and Hospitalizations Among Women Receiving Adjuvant Chemotherapy for Early Breast Cancer

The authors conclude that emergency room visits and hospitalization are common among patients with early breast cancer receiving chemotherapy and significantly higher than among controls.

Repeated assessments of symptom severity improve predictions for risk of death among patients with cancer

CONTEXT

Although prior studies show the importance of self-reported symptom scores as predictors of cancer survival, most are based on scores recorded at a single point in time.

OBJECTIVES

To show that information on repeated assessments of symptom severity improves predictions for risk of death and to use updated symptom information for determining whether worsening of symptom scores is associated with a higher hazard of death.

METHODS

This was a province-based longitudinal study of adult outpatients who had a cancer diagnosis and had assessments of symptom severity. We implemented a time-to-death Cox model with a time-varying covariate for each symptom to account for changing symptom scores over time. This model was compared with that using only a time-fixed (baseline) covariate for each symptom. The regression coefficients of each model were derived based on a randomly selected 60% of patients, and then, the predictive performance of each model was assessed via concordance probabilities when applied to the remaining 40% of patients.

RESULTS

This study had 66,112 patients diagnosed with cancer and more than 310,000 assessments of symptoms. The use of repeated assessments of symptom scores improved predictions for risk of death compared with using only baseline symptom scores. Increased pain and fatigue and reduced appetite were the strongest predictors for death.

CONCLUSION

If available, researchers should consider including changing information on symptom scores, as opposed to only baseline information on symptom scores, when examining hazard of death among patients with cancer. Worsening of pain, fatigue, and appetite may be a flag for impending death.

Home care utilization and costs in stage IV lung cancer: a Canadian public payer experience

SUMMARY 

Background: Lung cancer (LC) is a leading cause of morbidity and mortality and there is limited information on the type, quantity and cost of home care services (HCS) for LC. Aim: The objectives of this study include: identifying a stage IV LC cohort; determining the utilization and costs of HCS for the stage IV LC cohort; and comparing HCS utilization and costs by phase of disease. Methods: New cases of stage IV LC were extracted from a provincial cancer registry and linked to administrative datasets. HCS utilization and costs (2009 Canadian dollars [CAD]) for stage IV cases were determined from a public payer perspective and by disease phase. Results: There are 4616 stage IV LC patients who used HCS.. The mean number of HCS visits per 30 days was 7.7 and the mean cost per 30 days was CAD$798 for terminal-phase patients. Conclusion: HCS costs for stage IV patients are less expensive than other health resources.

The Choosing Wisely Canada cancer initiative

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Background: Choosing Wisely Canada is a campaign modelled after Choosing Wisely in the USA and aims, through a pan-Canadian cancer physician-based consensus process, to identify a list of low value or harmful cancer services/practices frequently used in Canada. The following describes the approach taken for this work related to cancer in Canada. Methods: A Task Force approach was used, facilitated by the Canadian Partnership Against Cancer (CPAC), and included representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: (1) identify potentially relevant items and a framework for their subsequent selection; (2) develop a long list; (3) refine and reduce the long list to a short list; and (4) select and endorse a final list of low value or harmful cancer practices. Phases 2–4 followed a framework-driven consensus process and used a series of electronic surveys and voting processes. Results: For Phase 1, 66 cancer relevant practices were initially identified. The framework for subsequent selection included: (1) the size of population to which the practice is relevant; (2) frequency of use in Canada; (3) cost; (4) evidence of low value/harm; and (5) potential for change in use of the practice. The long list (41 practices) was refined and reduced to a short list of 19 practices and a final list including 10 practices. Of these, 5 are completely new, and 3 are revisions/adaptations practices from USA Choosing Wisely. Of the 10 practices, 6 are involve multiple disease sites, while 4 practices are disease-site specific. One practice relates to diagnosis, 6 are treatment- focussed, 2 target surveillance/survivorship, while one practice spans the cancer continuum from diagnosis through survivorship. Conclusions: Through CPAC facilitation, the collective input and work of three professional oncology societies informed this initiative. The content of the final list will be officially released through Choosing Wisely Canada in October 2014, and will be fully revealed at the ASCO Quality Care Symposium.

Processes of care in the multidisciplinary treatment of gastric cancer: results of a RAND/UCLA expert panel

IMPORTANCE

There is growing interest in reducing the variations and deficiencies in the multidisciplinary management of gastric cancer.

OBJECTIVE

To define optimal treatment strategies for gastric adenocarcinoma (GC).

DESIGN, SETTING, AND PARTICIPANTS

RAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries.

INTERVENTIONS

Gastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care.

MAIN OUTCOMES AND MEASURES

Panelists scored 416 scenarios regarding treatment scenarios for appropriateness from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Agreement was reached when 12 of 16 panelists scored the scenario similarly. Appropriate scenarios agreed on were subsequently scored for necessity.

RESULTS

For patients with T1N0 disease, surgery alone was considered appropriate, while there was no agreement over surgery alone for patients T2N0 disease. Perioperative chemotherapy was appropriate for patients who had T1-2N2-3 or T3-4 GC without major symptoms. Adjuvant chemoradiotherapy was classified as appropriate for T1-2N1-3 or T3-4 proximal GC and necessary for T1-2N2-3 or T3-4 distal GC. There was no agreement regarding surveillance imaging and endoscopy following gastrectomy. Surveillance endoscopy was deemed to be appropriate after endoscopic resection. For patients with metastatic GC, surgical resection was considered inappropriate for those with no major symptoms, unless the disease was limited to positive cytology alone, in which case there was disagreement.

CONCLUSIONS AND RELEVANCE

Patients with GC being treated with curative intent should be considered for multimodal treatment. For patients with incurable disease, surgical interventions should be considered only for the management of major bleeding or obstruction.