Quality of care for comorbid conditions during the transition to survivorship: differences between cancer survivors and noncancer controls

Pain management for post-treatment survivors of complex cancers: a qualitative study of opioids and cannabis

Aim: We aimed to understand experiences with opioids and cannabis for post-treatment cancer survivors. Patients & methods: We conducted seven focus groups among head and neck and lung cancer survivors, using standard qualitative methodology to explore themes around 1) post-treatment pain and 2) utilization, perceived benefits and perceived harms of cannabis and opioids. Results & conclusion: Survivors (N = 25) experienced addiction fears, stigma and access challenges for both products. Opioids were often perceived as critical for severe pain. Cannabis reduced pain and anxiety for many survivors, suggesting that anxiety screening, as recommended in guidelines, would improve traditional pain assessment. Opioids and cannabis present complex harms and benefits for post-treatment survivors who must balance pain management and minimizing side effects.

Multimorbidity in people living with and beyond cancer: a scoping review

Globally, both cancer incidence and survival are increasing. Early cancer detection and improved treatment means many people with cancer will survive for ten or more years following diagnosis. Multimorbidity, defined as two or more chronic conditions, is up to three times higher in people living with and beyond cancer (LWBC) compared to the general population. This scoping review summarises the research evidence on the association between cancer and multimorbidity in people LWBC. It explores five key domains in people LWBC: 1) prevalence of multimorbidity, 2) association between ethnicity and socio-economic status (SES) and multimorbidity, 3) association between health status and multimorbidity, 4) adverse health consequences of cancer and related treatments, and 5) whether being a cancer survivor impacts treatment received for multimorbidity. It focuses on ten common cancers with high survival rates: prostate, breast, non-Hodgkin lymphoma, bowel/colorectal, kidney, head and neck, bladder, leukaemia, uterine and myeloma. A search of Medline, CINAHL, Embase, PsychINFO and Web of Science databases identified 9,460 articles, 115 of which met the inclusion criteria. Articles were included in the review that involved multimorbidity in adult cancer patients. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. This review included work from 20 countries, most studies were from the US (44%). The results showed that the most common long-term conditions in people LWBC were: hypertension, heart conditions, depression, COPD, and diabetes. The most reported incident comorbidities after a cancer diagnosis were congestive heart failure, chronic pain, and chronic fatigue. Multimorbidity tended to be higher amongst people LWBC from ethnic minority groups and those with lower SES. Quality of life was poorer in people LWBC with multimorbidity. The review identified the need for a uniform approach to measure multimorbidity in cancer patients across the world. Further research is required to compare multimorbidity before and after a cancer diagnosis, to explore the association of multimorbidity with ethnicity and socio-economic status and to determine whether a cancer diagnosis impacts care received for multimorbidity in people LWBC.

Assessing the Effect of Cancer Diagnosis on Beliefs about Comorbid Diabetes

OBJECTIVES

Increasingly, patients diagnosed with cancer also live with chronic comorbidities, and it is important to understand the impact of a new cancer diagnosis on perceptions about preexisting conditions. This study assessed the effect of cancer diagnosis on beliefs about comorbid diabetes mellitus and assessed changes in beliefs about cancer and diabetes over time.

DATA SOURCES

We recruited 75 patients with type 2 diabetes who were newly diagnosed with early-stage breast, prostate, lung, or colorectal cancer and 104 age-, sex-, and hemoglobin A1c-matched controls. Participants completed the Brief Illness Perception Questionnaire four times over 12 months. The authors examined within-patient and between-group differences in cancer and diabetes beliefs at baseline and over time.

RESULTS

Overall, diabetes beliefs did not differ between cancer patients and controls at baseline. Cancer patients' beliefs about diabetes varied significantly over time; they reported less concern about cancer, less emotional effect, and greater cancer knowledge over time. Participants without cancer were significantly more likely to report that diabetes affected their life across all time points, though this effect did not persist after adjustment for sociodemographic variables.

CONCLUSION

While all patients' diabetes beliefs were similar at baseline and 12 months, cancer patients' beliefs about both illnesses fluctuated during the months following cancer diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can play a key role in recognizing the effects of cancer diagnosis on beliefs about comorbid conditions and fluctuations in these beliefs during treatment. Assessing and communicating patient beliefs between oncology and other practitioners could produce more effective care plans based on patients' current outlook on their health.

A comparison of cardiovascular and pulmonary morbidities and risk factors in breast cancer survivors compared to an age-matched female control group in the Lifelines prospective population cohort

PURPOSE

To provide more insight into late treatment-related toxicities among breast cancer (BC) survivors by comparing morbidities and risk factors between BC survivors and age-matched controls.

MATERIALS AND METHODS

All female participants diagnosed with BC before inclusion in Lifelines, a population-based cohort in the Netherlands, were selected and matched 1:4 to female controls without any oncological history on birth year. Baseline was defined as the age at BC diagnosis. Outcomes were obtained from questionnaires and functional analyses performed at entry to Lifelines (follow-up 1; FU1) and several years later (FU2). Cardiovascular and pulmonary events were defined as morbidities that were absent at baseline but present at FU1 or FU2.

RESULTS

The study consisted of 1,325 BC survivors and 5,300 controls. The median period from baseline (i.e., BC treatment) to FU1 and FU2 was 7 and 10 years, respectively. Among BC survivors more events of heart failure (OR: 1.72 [1.10-2.68]) and less events of hypertension (OR: 0.79 [0.66-0.94]) were observed. At FU2, more electrocardiographic abnormalities were found among BC survivors compared to controls (4.1% vs. 2.7%, respectively; p = 0.027) and Framingham scores for the 10-year risk of coronary heart disease were lower (difference: 0.37%; 95% CI [-0.70 to -0.03%]). At FU2, BC survivors had more frequently a forced vital capacity below the lower limit of normal than controls (5.4% vs. 2.9%, respectively; p = 0.040).

CONCLUSION

BC survivors are at risk of late treatment-related toxicities despite a more favourable cardiovascular risk profile compared to age-matched female controls.

Influence of Diabetes Mellitus on Oncological Outcomes for Patients Living With Cancer

PURPOSE

The purpose of this meta-analysis was to examine the association between preexisting diabetes in persons living with cancer on diabetes and oncology-related health outcomes. Understanding this association is of priority because the incidence of both cancer and diabetes mellitus is increasing worldwide.

METHODS

A comprehensive review of the literature was conducted in collaboration with an expert health sciences librarian. Two authors independently conducted the screening, data collection, and extraction processes. The risk of bias was assessed using several tools, depending on the study design. Relative risks with 95% confidence intervals were calculated. The alpha threshold was 0.05. All analyses were performed using R statistical software (Metaphor and Demeter packages).

RESULTS

A total of 45 studies met the selection criteria, but 23 were excluded from the synthesis because they did not have the ranked outcome or correct comparison (persons with and without diabetes), totaling 22 studies included in the meta-analysis. In comparison to participants without preexisting diabetes, participants with preexisting diabetes and cancer were found to have a significantly higher risk of infection and cardiovascular, neurological, gastrointestinal, hepatic, and renal complications. Concurrent preexisting diabetes and cancer were also associated with increased health care service utilization and length of hospital stay.

CONCLUSION

The findings from this review highlight the importance of optimal concurrent management of both diseases by overcoming the compartmentalization of medical specializations through (1) integrated, multidisciplinary, shared, and coordinated clinical care pathways between oncology and diabetes health care providers/teams and (2) the continued development of evidence-based clinical guidelines.

Racial disparities in diabetes care among incident breast, prostate, and colorectal cancer survivors: a SEER Medicare study

BACKGROUND

Many cancer survivors with co-morbid diabetes receive less diabetes management than their non-cancer counterparts. We sought to determine if racial/ethnic disparities exist in recommended diabetes care within 12 months of an incident breast, prostate, or colorectal cancer diagnosis. Because co-morbid diabetes decreases long-term survival, identifying predictors of guideline-concordant diabetes care is important.

METHODS

Using the Surveillance, Epidemiology, and End Results cancer registry linked to Medicare claims, we included beneficiaries aged 67+ years with diabetes and incident, non-metastatic breast, prostate, or colorectal cancer between 2008 and 2013. Primary outcomes were diabetes care services 12 months after diagnosis: (1) HbA1c test, (2) eye exam, and (3) low-density lipoprotein (LDL) test. Using modified Poisson models with robust standard errors, we examined each outcome separately.

RESULTS

We included 34,643 Medicare beneficiaries with both diabetes and cancer. Mean age at diagnosis was 76.1 (SD 6.2), 47.2% were women; 35% had breast, 24% colorectal, and 41% prostate cancer. In the 12 months after incident cancer diagnosis, 82.4% received an HbA1c test, 55.3% received an eye exam, 77.8% had an LDL test, and 42.0% received all three tests. Compared to non-Hispanic Whites, Blacks were 3% (95% CI 0.95-0.98) less likely to receive a HbA1c test, 10% (95% CI 0.89-0.92) less likely to receive a LDL test, and 8% (95% 0.89-0.95) less likely to receive an exam eye. Blacks and Hispanics were 16% (95% CI 0.81-0.88) and 7% (0.88-0.98) less likely to receive all three tests, after accounting for confounders. Racial/ethnic differences persisted across cancer types.

CONCLUSION

Blacks and Hispanics with breast, prostate, and colorectal cancer and diabetes received less diabetes care after cancer diagnosis compared to non-Hispanic Whites. Differences were not explained by socio-economic factors or clinical need.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings are concerning given the high prevalence of diabetes and poor cancer outcomes among racial/ethnic minorities. The next step in this line of inquiry is to determine why minorities are less likely to receive comprehensive diabetes care in order to develop targeted strategies to increase receipt of appropriate diabetes management for these vulnerable populations.

Healthcare use, sickness absence, and disability pension among colorectal cancer survivors and population references in Sweden

BACKGROUND

Colorectal cancer (CRC) has negative long-term impacts on survivors' health and work capacity. We aimed to investigate specialized healthcare use and sickness absence and disability pension among CRC survivors and matched references.

MATERIAL AND METHODS

In this longitudinal register-based cohort study, 6679 patients with a first primary CRC in 2008-2011 (when aged 18-62) and 26,716 CRC-free matched references were followed from 2 years before up to 5 years after diagnosis date. Mean numbers of hospital days and outpatient visits were illustrated for survivors and references for the 7-year period. Crude and adjusted mean numbers of sickness absence/disability pension net days were calculated for post-diagnosis Years 3 and 5.

RESULTS

Survivors' healthcare use was higher compared to their references throughout the 7 years around CRC diagnosis and was mostly due to CRC, secondary neoplasms, and digestive disorders. In Year 5, survivors had 1.94 mean outpatient visits and 2.13 mean inpatient days (compared to 1.00 and 0.82 for references, respectively). Survivors' adjusted mean sickness absence/disability pension days amounted to 85 d in Year 3 and 77 in Year 5 (compared to 57 and 54 d in the references). Higher mean number of future days was found among women, lower-educated, foreign-born, with previous comorbidities or previous mental disorders. Those with many sickness absence days in 2 years pre-diagnosis had the highest number of future sickness absence/disability pension days.

CONCLUSIONS

Post-diagnostic healthcare use remained high among CRC survivors, mostly due to cancer (CRC and other neoplasms) and digestive diagnoses. Their sickness absence and disability pension decreased gradually over the period but remained higher than among references. Pre-morbid characteristics may be used in early work-related clinical planning for the survivors.

Providers' mediating role for medication adherence among cancer survivors

Background

We conducted a mediation analysis of the provider team’s role in changes to chronic condition medication adherence among cancer survivors.

Methods

We used a retrospective, longitudinal cohort design following Medicare beneficiaries from 18-months before through 24-months following cancer diagnosis. We included beneficiaries aged ≥66 years newly diagnosed with breast, colorectal, lung or prostate cancer and using medication for non-insulin anti-diabetics, statins, and/or anti-hypertensives and similar individuals without cancer from Surveillance, Epidemiology, and End Results-Medicare data, 2008–2014. Chronic condition medication adherence was defined as a proportion of days covered ≥ 80%. Provider team structure was measured using two factors capturing the number of providers seen and the historical amount of patient sharing among providers. Linear regressions relying on within-survivor variation were run separately for each cancer site, chronic condition, and follow-up period.

Results

The number of providers and patient sharing among providers increased after cancer diagnosis relative to the non-cancer control group. Changes in provider team complexity explained only small changes in medication adherence. Provider team effects were statistically insignificant in 13 of 17 analytic samples with significant changes in adherence. Statistically significant provider team effects were small in magnitude (<0.5 percentage points).

Conclusions

Increased complexity in the provider team associated with cancer diagnosis did not lead to meaningful reductions in medication adherence. Interventions aimed at improving chronic condition medication adherence should be targeted based on the type of cancer and chronic condition and focus on other provider, systemic, or patient factors.

Opioid Use Disorder and Overdose in Older Adults With Breast, Colorectal, or Prostate Cancer

BACKGROUND

Despite high rates of opioid therapy, evidence about the risk of preventable opioid harms among cancer survivors is underdeveloped. Our objective was to estimate the odds of opioid use disorder (OUD) and overdose following breast, colorectal, or prostate cancer diagnosis among Medicare beneficiaries.

METHODS

We conducted a retrospective cohort study using 2007-2014 Surveillance, Epidemiology, and End Results-Medicare data for cancer survivors with a first cancer diagnosis of stage 0-III breast, colorectal, or prostate cancer at age 66-89 years between 2008 and 2013. Cancer survivors were matched to up to 2 noncancer controls on age, sex, and Surveillance, Epidemiology, and End Results region. Using Firth logistic regression, we estimated adjusted 1-year odds of OUD or nonfatal opioid overdose associated with a cancer diagnosis. We also estimated adjusted odds of OUD and overdose separately and by cancer stage, prior opioid use, and follow-up time.

RESULTS

Among 69 889 cancer survivors and 125 007 controls, the unadjusted rates of OUD or nonfatal overdose were 25.2, 27.1, 38.9, and 12.4 events per 10 000 patients in the noncancer, breast, colorectal, and prostate samples, respectively. There was no association between cancer and OUD. Colorectal survivors had 2.3 times higher odds of opioid overdose compared with matched controls (adjusted odds ratio = 2.33, 95% confidence interval  = 1.49 to 3.67). Additionally, overdose risk was greater in those with more advanced disease, no prior opioid use, and preexisting mental health conditions.

CONCLUSIONS

Opioid overdose was a rare, but statistically significant, outcome following stage II-III colorectal cancer diagnosis, particularly among previously opioid-naïve patients. These patients may require heightened screening and intervention to prevent inadvertent adverse opioid harms.

Healthcare utilization and spending among older patients diagnosed with Non-Hodgkin lymphoma

BACKGROUND

Developing appropriate care models for patients diagnosed with non-Hodgkin lymphoma (NHL) >65y require examination of current healthcare utilization patterns and cost, but non-malignant condition-specific utilization and Medicare spending among older patients has not been characterized.

METHODS

Using SEER-Medicare, 14,533 patients diagnosed with NHL at age > 65 between 2008 and 2015 and a comparable non-cancer cohort (n = 14,533) were identified. Hospitalizations and outpatient visits for 109 non-malignant conditions were grouped into ten categories, allowing condition-specific utilization and spending calculation from diagnosis to 5y, censoring at blood or marrow transplantation, 6mo prior to death or end (12/31/2016). Using the 90th percentile as a cut-off, factors associated with high-hospitalization rates and high-spending were evaluated.

RESULTS

Patients with NHL were 1.5-fold more likely to be hospitalized and 1.8-fold more likely to experience outpatient visits when compared with the non-cancer cohort. Patients with NHL had greater aging-related, cardiovascular, and gastrointestinal hospitalizations than controls (p < 0.001). Average Medicare spending/visit was higher for patients with NHL (hospitalization: $16,950 vs. $13,474, p < 0.001; outpatient: $1176 vs. $392, p < 0.001). Factors associated with high-utilization and high-spending included diffuse large B cell lymphoma subtype, non-white race, and residence in low-education area.

CONCLUSIONS

Older patients with NHL experienced higher utilization and higher spending per-utilization compared to a non-cancer cohort over five years from cancer diagnosis. Clinical and demographic sub-groups demonstrated increased risk for the highest spending and utilization. The substantial utilization and spending for non-malignant conditions among older patients with NHL provides quantifiable evidence for survivor-adapted healthcare management policies.

The quality of diabetes care among cancer survivors: a retrospective cohort study

BACKGROUND

As cancer survivorship continues to improve, management of co-morbid diabetes has become an increasingly important determinant of health outcomes for people with cancer. This study aimed to compare indicators of diabetes quality of care between people with diabetes and without a history of cancer.

METHODS

We used the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of Ontario primary care EMR charts linked to administrative data, to identify people with diabetes and at least 1 year follow-up. Persons with a history of cancer were matched 1:2 on age, sex and diabetes duration to those without cancer. We compared recommended diabetes quality of care indicators between persons with and without cancer using a matched cohort analysis.

RESULTS

Among 229,627 people with diabetes, we identified 2275 people with cancer and 4550 matched controls; 86.5% had diabetes diagnosed after cancer. Compared to controls, cancer people with diabetes were significantly less likely to receive ACE inhibitors or angiotensin receptor blockers (OR 0.75 [95% CI 0.64-0.89]), receive statin therapy if age 50-80 years (OR 0.79 [95% CI 0.68-0.92]) and achieve an LDL cholesterol level <2.0 mmol/L (OR 0.82 [95% CI 0.74-0.91]). There were no differences in recommended clinical testing or achieving A1C and blood pressure targets between groups.

CONCLUSION

Cancer survivors with diabetes are less likely to receive recommended cardiovascular risk-reducing therapies compared to people with diabetes without cancer of similar age, sex and diabetes duration. Further studies are warranted to determine if these associations are linked to worse survival, cardiovascular outcomes and quality of life.

Life goes on… Patient perspectives on having a cancer diagnosis and other comorbid diseases: A qualitative study

OBJECTIVES

Due to a growing population with both cancer and chronic diseases, we explored patients' experiences of living with a cancer diagnosis and comorbidities, the possible effects on everyday living and management of comorbidities.

METHODS

Semi-structured interviews were conducted during 2016 with 15 patients in Denmark, with finished cancer treatment and preexisting comorbidities. Analysis was performed by Systematic Text Condensation.

RESULTS

Symptoms which disrupted everyday function were given attention, regardless of the disease from which the symptoms originated. The awareness of cancer and comorbidities constituted an inverse process over time. Most patients perceived cancer as being transient, whereas experiences of comorbidities varied from ignorance to worry. Most patients reported maintaining their chronic illness consultations with their general practitioner as before cancer.

CONCLUSION

Patients prioritized an everyday life with normal chores highly in contrast to paying attention to diseases. Disruptive symptoms, rather than specific diseases, took up patients' attention. Cancer did not change the patients' attendance at chronic care consultations. General practitioners should focus on maintaining the patient's functional level in everyday life. Further, they should continue to prioritize the chronic care management, as this might increase the patients' own view of the importance of self-management.

Changes in chronic medication adherence in older adults with cancer versus matched cancer-free cohorts

OBJECTIVES

A cancer diagnosis can influence medication adherence for chronic conditions by shifting care priorities or reinforcing disease prevention. This study describes changes in adherence to medications for treating three common chronic conditions - diabetes, hyperlipidemia, and hypertension - among older adults newly diagnosed with non-metastatic breast, colorectal, lung, or prostate cancer.

METHODS

We identified Medicare beneficiaries aged ≥66 years newly diagnosed with cancer and using medication for at least one chronic condition, and similar cohorts of matched individuals without cancer. To assess medication adherence, proportion of days covered (PDC) was measured in six-month windows starting six-months before through 24 months following cancer diagnosis or matched index date. Generalized estimating equations were used to estimate difference-in-differences (DID) comparing changes in PDCs across cohorts using the pre-diagnosis window as the referent. Analyses were run separately for each cancer type-chronic condition combination.

RESULTS

Across cancer types and non-cancer cohorts, adherence was highest for anti-hypertensives (90-92%) and lowest for statins (77-79%). In older adults with colorectal and lung cancer, adherence to anti-diabetics and statins declined post-diagnosis compared with the matched non-cancer cohorts, with estimates ranging from a DID of -2 to -4%. In older adults with breast and prostate cancer cohorts, changes in adherence for all medications were similar to non-cancer cohorts.

CONCLUSION

Our findings highlight variation in medication adherence by cancer type and chronic condition. As many older adults with early stage cancer eventually die from non-cancer causes, it is imperative that cancer survivorship interventions emphasize medication adherence for other chronic conditions.

Preventive health service use among survivors of adolescent and young adult cancer

Preventive health screenings are essential for survivors of adolescent and young adult (AYA) cancer survivors, who are at greater risk for non-cancer related death compared to individuals without a history of cancer. However, little research exists examining their use of screening services. In order to identify potential areas for targeted improvements in AYA survivorship care, we examined adherence to United States Preventive Services Task Force (USPSTF) screening recommendations among members of Kaiser Permanente Southern California. The study population included individuals diagnosed with cancer between ages 15-39 from 2000 to 2012 who survived at least two years post-diagnosis (n = 6779) and a matched cohort of non-cancer comparisons (n = 25640). To assess adherence to screening services, we calculated a Prevention Index (PI, proportion of person-time covered by receipt of recommended clinical preventive services relative to the time eligible) for every individual and the distributions for each service. We also evaluated predictors for adherence using logistic regression. Adherence was significantly (p-value < 0.05) higher among survivors than non-cancer subjects for screenings for dyslipidemia (71.16% and 65.94, respectively), hypertension (97.43% and 89.11%), cervical cancer (87.36% and 84.45%), colorectal cancer (83.23% and 58.27%), and influenza vaccination (36.79% and 33.21%). The logistic regression showed that survivors were significantly more likely to adhere to guidelines compared to non-cancer peers for all screenings except breast cancer, with the greatest difference found for colorectal cancer (odds ratio: 5.04, p-value: <0.01). While AYA survivors appear to use preventive screenings more than comparisons, there is room for improvement for certain services, most notably for influenza vaccination.

Cardiovascular Screening and Lipid Management in Breast Cancer Survivors

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death among breast cancer (BC) survivors. BC survivors are at increased risk of CVD due to a higher prevalence of risk factors. Current data are limited on the cardiovascular screening practices and lipid management in this population in primary care settings.

METHODS

A retrospective case control study was performed with 105 BC survivors and 210 matched controls (based on age and medical comorbidities of diabetes, hypertension, and hyperlipidemia). BC survivors were established with primary care practices within a large academic institution and had completed primary cancer treatment. Data on screening for CVD and lipid management were collected via a retrospective chart review.

RESULTS

The average BC survivor was 63 years old, with 9 years since diagnosis. Compared with matched controls, BC survivors had more cholesterol screening (88% vs 70%, P < .001) and active statin prescriptions (63% vs 40%, P < .05) if indicated by the Atherosclerotic Cardiovascular Disease Calculator. There were no differences in CVD screening in White and African American BC survivors. However, African American BC survivors were more likely to have hypertension (P < .01) and have a body mass index in the overweight and obese category (P < .001) than White BC survivors. Older BC survivors were more likely to receive cholesterol screening.

DISCUSSION

This study demonstrates that BC survivors who have an established primary care provider have improved cholesterol screening and statin therapy based on their risk of developing chronic diseases.

Use of real-world data to study health services utilisation and comorbidities in long-term breast cancer survivors (the SURBCAN study): study protocol for a longitudinal population-based cohort study

INTRODUCTION

Breast cancer has become a chronic disease due to survival improvement and the need to monitor the side effects of treatment and the disease itself. The aim of the SURBCAN study is to describe comorbidity, healthcare services use and adherence to preventive recommendations in long-term breast cancer survivors and to compare them with those in women without this diagnosis in order to improve and adapt the care response to this group of survivors.

METHODS AND ANALYSIS

Population-based retrospective cohort study using real-world data from cancer registries and linked electronic medical records in five Spanish regions. Long-term breast cancer survivors diagnosed between 2000 and 2006 will be identified and matched by age and administrative health area with women without this diagnosis. Sociodemographic and clinical variables including comorbidities and variables on the use of health services between 2012 and 2016 will be obtained from databases in primary and hospital care. Health services use will be assessed through the annual number of visits to primary care professionals and to specialists and through annual imaging and laboratory tests. Factors associated with healthcare utilisation and comorbidities will be analysed using multilevel logistic regression models. Recruitment started in December 2018.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Parc de Salut Mar. The results of the study will be published in a peer-reviewed journal and will be presented at national and international scientific conferences and at patient associations.

TRIAL REGISTRATION NUMBER

This protocol is registered in Clinical Trials.gov (identifier: NCT03846999).

Impact of clinical pharmacy recommendations and patient counselling program among patients with diabetes and cancer in outpatient oncology setting

INTRODUCTION

The simultaneous occurrence of diabetes and cancer may complicate the management of both conditions resulting in poor prognosis and more deterioration of patient-related outcomes.

OBJECTIVE

To assess the effective provision of clinical pharmacy services and pharmacist-led counselling program on improving patient-related outcomes among patients with diabetes and newly diagnosed with cancer during chemotherapy administration.

METHODS

A single-centre, prospective, randomised, controlled study was carried out on patients with diabetes newly diagnosed with cancer during chemotherapy administration at the outpatient oncology setting. Patients were assigned as a normal care group receiving only normal care by the oncology care providers and an intervention group receiving both normal and clinical pharmacy care through an extensive oral and written patient education, pharmacotherapy optimisation and regular recommendations for diabetic self-care activities with three-month follow-up.

RESULTS

Patients within the intervention group showed a better glycaemic control (p = .049), a significant increase in medication adherence (p = .0049), a significant increase in diabetes self-care activities, including diet (p = .037), self-monitoring of blood glucose (p = .027) and foot care (p = .0085) and reported a lower deterioration in quality of life.

CONCLUSION

Patients with diabetes and cancer receiving chemotherapy experienced improved patient-related outcomes after clinical pharmacy intervention and counselling program compared to the normal care group.

Rates of underuse of statins among cancer survivors versus controls: NHANES 2011-2016

PURPOSE

Cardiovascular disease (CVD) is a major non-cancer cause of mortality among cancer survivors, and statin therapy is the mainstay of cardiovascular risk management. However, little is known about adherence to statin therapy relative to current guidelines for the management of cholesterol among cancer survivors. We investigated the prevalence of statin-eligible but untreated individuals among cancer survivors and factors associated with underuse of statins.

METHODS

We used US National Health and Nutrition Examination Survey data (2011-2016) and identified 706 cancer survivors and matched controls (1:2) by age and sex. We identified participants who met the American College of Cardiology/American Heart Association (2018) guidelines but were not currently in treatment. We estimated the proportion of patients who were statin-eligible but untreated and performed multivariable logistic regression analysis to identify the factors associated with underuse of statins.

RESULTS

The mean age of the total sample was 62.2 years (standard deviation, 9.1). Among the total participants, 37.5% of cancer survivors and 37.2% of controls were statin-eligible but untreated. The crude statin-eligible untreated proportion was 41.2% among cancer survivors who had received a cancer diagnosis within 3 years and 40.3% among long-term survivors of 10 years or more. In multivariate analysis, old age, male sex, lack of a usual source of care, current smoking, and low household income were significantly associated with statin-eligible untreated status.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

More than one-third of cancer survivors were statin-eligible but untreated under current guidelines. There is room for improvement to reduce the burden of non-cancer mortality by managing traditional cardiovascular risk factors.

Diabetes care management patterns before and after a cancer diagnosis: A SEER-Medicare matched cohort study

BACKGROUND

Diabetes places patients with cancer at an increased risk of infections, hospitalizations, and mortality. The objective of the current study was to characterize diabetes care management patterns among patients with cancer in the year before and, separately, after cancer diagnosis. The authors hypothesized that diabetes care declines after a diagnosis of cancer.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims data was used. The authors included diabetic beneficiaries aged ≥65 years who were diagnosed with incident, nonmetastatic breast, prostate, or colorectal cancer between 2008 and 2013. Controls were diabetic Medicare beneficiaries in SEER regions who did not have cancer. Cases were matched to controls based on age, sex, Charlson Comorbidity Index, and diabetes severity. Primary outcomes were diabetes care received over 12 months: 1) hemoglobin A1c testing; 2) eye examination; and 3) low-density lipoprotein testing. Using a difference-in-difference (DID) approach, the authors examined use differences 12 months before to after diagnosis for patients with cancer and controls. To avoid capturing testing related to diagnosis and not diabetes management, the authors implemented a 90-day washout period (45 days before and/or after diagnosis).

RESULTS

A total of 32,728 diabetic patients with cancer and 32,728 matched noncancer controls were included. After diagnosis, patients with cancer were found to have modest, but significantly lower, rates of diabetes care use compared with controls. Patients with cancer had greater declines in hemoglobin A1c testing (DID, 2.4%; 95% CI, 1.7%-3.0%), low-density lipoprotein testing (DID, 4.3%; 95% CI, 3.6%-5.0%), and receipt of all diabetes indicators (DID, 2.7%; 95% CI, 1.8%-3.5%) 12 months before to after diagnosis.

CONCLUSIONS

Compared with controls, less diabetes care use was observed among patients with cancer in the year after diagnosis. Understanding and addressing the reasons for this may improve outcomes in this population.

Clinical trajectories, healthcare resource use, and costs of long-term hematopoietic stem cell transplantation survivors: a latent class analysis

PURPOSE

To identify patterns of healthcare utilization in allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients and evaluate factors associated with high-need and high-cost post-transplantation care.

METHODS

Latent class analysis of a retrospective cohort of long-term allogeneic (n = 436) and autologous (n = 888) HSCT survivors within the Truven MarketScan database (2009-2014). We assessed factors associated with the latent classes by comparing post-transplantation healthcare utilization including inpatient admissions and length of stay, emergency room visits, specialist visits, and primary care provider visits.

RESULTS

Four utilization classes were identified in allogeneic and autologous HSCT recipients: (i) outpatient specialist care dominant (51.8% and 57.3%), (ii) outpatient primary care dominant (10.3% and 25.7%), (iii) outpatient/inpatient balanced (20.6% and 13.5%), and (iv) inpatient dominant (17.2% and 3.5%). Mean monthly healthcare expenditures in the inpatient dominant utilization class were $41,097 and $25,556 for allogeneic and autologous survivors, respectively, which were two to five times higher compared with other classes during the 2-year post-transplantation period. Factors associated with the high utilization class were transfusion (OR = 1.87, 95% CI 1.06-3.30) and 100-day post-transplant graft-versus-host-disease (OR = 1.76, 95% CI 1.05-2.94) in allogeneic HSCT; higher baseline Charlson comorbidity index (OR = 1.45, 95% CI 1.19-1.76) in autologous HSCT.

CONCLUSION

Based on distinct patterns of healthcare utilization following HSCT, we identified factors associated with higher resource utilization and greater healthcare related expenditures.

IMPLICATIONS FOR CANCER SURVIVORS

Earlier identification of high-cost and high-need HSCT long-term survivors could pave the way for clinicians to offer more continuous engagement in survivorship care delivery.

General practitioners' perspectives on chronic care consultations for patients with a history of cancer: a qualitative interview study

Background

General practitioners (GPs) are responsible for managing chronic care in the growing population of patients with comorbid chronic conditions and cancer. Studies have shown, however, that cancer patients are less likely to receive appropriate chronic care compared to patients without cancer. Patients say that how GPs engage in the care of comorbidities influences their own priority of these conditions. No studies have explored GPs’ attitudes to and prioritization of chronic care in patients who have completed primary cancer treatment. This study aims to explore GPs’ experiences, prioritization of, and perspectives on treatment and follow-up of patients with cancer and comorbidity.

Methods

Semi-structured interviews were conducted during 2016 with 13 GPs in Region Zealand in Denmark. We used Systematic Text Condensation in the analysis.

Results

All participating GPs said that chronic care in patients with a history of cancer was a high priority, and due to a clear structure in their practice, they experienced that few patients were lost to follow-up. Two different approaches to chronic care consultations were identified: one group of GPs described them as imitating outpatient clinics, where the GP sets the agenda and focuses on the chronic condition. The other group described an approach that was more attuned to the patient’s agenda, which could mean that chronic care consultations served as an “alibi” for the patients to disclose other matters of concern.

Both groups of GPs said that chronic care consultations for these patients supported normalcy, but in different ways. Some GPs said that offering future appointments in the chronic care process gave patients hope and a sense of normalcy. Other GPs strove for normalcy by focusing exclusively on the chronic condition and dealing with cancer as cured.

Conclusions

The participating GPs gave a high priority to chronic care in patients with a history of cancer. Some GPs, however, followed a rigorous agenda. GPs should be aware that a very focused and biomedical approach to chronic care might increase fragmentation of care and collide with a holistic and patient-centered approach. It could also affect GPs’ self-perception of their role and the core values of general practice.

Continuity of Care, Follow-Up Care, and Outcomes among Breast Cancer Survivors

This retrospective cohort study examined the effects of care continuity on the utilization of follow-up services and outcome of breast cancer patients (stages I-III) in the post-treatment phase of care. Propensity score matching and generalized estimation equations were used in the analysis of data obtained from national longitudinal databases. The continuity of care index (COCI) was calculated separately for primary care physicians (PCP) and oncologists. Our results revealed that breast cancer survivors with a higher oncology COCI were more likely than those with a lower oncology COCI to use mammography or breast ultrasound during the follow-up period (OR = 1.26, 95% CI: 1.19-1.32; OR = 1.12, 95% CI: 1.06-1.18; respectively). In terms of health outcomes, a higher oncology COCI was associated with a lower likelihood of hospitalization (OR = 0.78, 95% CI: 0.71-0.85) and emergency department use (OR = 0.88, 95% CI: 0.82-0.95). A higher PCP COCI was also associated with a lower likelihood of hospitalization (OR = 0.77, 95% CI: 0.70-0.85) and emergency department use (OR = 0.75, 95% CI: 0.68-0.82). Overall, this study determined that ambulatory care continuity is positively associated with the likelihood of using recommended follow-up care services and negatively associated with adverse health events among breast cancer survivors.

The impact of cancer on diabetes outcomes

BACKGROUND

Survival from many cancer types is steadily increasing, and as a result, a growing number of cancer patients will live with other chronic diseases, of which diabetes is one of the most prevalent. This study aims to describe the impact of cancer on health outcomes in patients with type 2 diabetes and to compare the effectiveness of a multifactorial intervention in diabetes patients with and without cancer.

METHODS

The randomized controlled trial Diabetes Care in General Practice (DCGP) included 1381 patients newly diagnosed with type 2 diabetes. Patients were randomized to either six years of structured personal diabetes care or routine care. In a post hoc analysis, we followed patients for 19 years in Danish national registries for the occurrence of diabetes-related outcomes. We used Cox regression models to estimate hazard ratios for outcomes.

RESULTS

At diagnosis 48 patients had cancer, and 243 patients were diagnosed with cancer during follow up. Patients with diabetes and cancer had excess all-cause mortality (HR 3.33; 95%CI 2.72-4.06), as well as an increased incidence of myocardial infarction (HR 1.76; 95%CI 1.29-2.39) and any diabetes-related outcome (HR 1.36; 95%CI 1.07-1.71). The intervention reduced the risk of both these endpoints in patients without cancer. Furthermore, there was no statistically significant difference in the effectiveness of the intervention among patients with and without cancer.

CONCLUSIONS

Diabetes patients with cancer had an increased risk of myocardial infarction and any diabetes-related outcome. The observed positive effect of structured personal diabetes care on clinical outcomes did not differ between patients with and without cancer. Attention to and prevention of diabetes complications in patients with both type 2 diabetes and cancer is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01074762 (February 24, 2010).

Pneumococcal Vaccination Utilization Among Hispanic Long-Term Colorectal Cancer Survivors: Cross-Sectional Assessment of Claims

Background

Colorectal cancer (CRC) is the second leading cancer-related cause of death in the United States. However, survivorship has been increasing. Both cancer survivors and underserved populations experience unique health-related challenges and disparities that may exist among long-term CRC survivors as it relates to routine preventive care, specifically pneumococcal (PNM) vaccination.

Objective

The aim of this study was to explore the relationship between long-term CRC survival and the receipt of PNM vaccine among Hispanic Medicare recipients compared with non-Hispanic populations.

Methods

This study is a cross-sectional analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare claims data examining ethnic differences in the receipt of PNM vaccination among long-term CRC survivors. Multivariable logistic regression models considered Hispanic ethnicity while controlling for sociodemographic characteristics, comorbidity score, age, tumor stage, and SEER registry.

Results

Our sample revealed 32,501 long-term CRC survivors, and 1509 identified as Hispanic (4.64%) based on an established SEER algorithm. In total, 16,252 CRC survivors, or 50.00% of our sample, received a PNM vaccination. We found that Hispanic CRC survivors had 10% decreased odds of having received a PNM vaccine compared with non-Hispanic survivors (P=.03).

Conclusions

Disparities likely exist in the utilization of PNM vaccination among long-term CRC survivors. Among Medicare beneficiaries, the use of claims data regarding PNM vaccination highlights the relatively poor utilization of guideline-directed preventive care.

Health care services use among long-term breast cancer survivors: a systematic review

PURPOSE

Long-term breast cancer survivors are women surviving at least 5 years after diagnosis. This systematic review aimed to summarize the main characteristics and patterns of healthcare service use (frequency of visits, health providers visited, and preventive care performed) among long-term breast cancer survivors.

METHODS

We used standard Cochrane Collaboration methods and searched the MEDLINE and EMBASE databases up to January 2018. We included English language observational studies reporting health service use among long-term cancer survivors. The quality of the studies was appraised through the ROBINS-I assessment tool. Two independent reviewers performed both the study quality assessment and the data extraction.

RESULTS

A total of 23 observational studies were included that reported data on health services use by long-term breast cancer survivors. Despite heterogeneity among studies, about half of them reported that breast cancer survivors visited a medical provider at least once a year, as recommended by breast cancer survival guidelines. Although survivors visited medical providers with the recommended frequency, a substantial number used specialist care instead of primary care during follow-up. The results showed underuse of the recommended annual mammogram.

CONCLUSIONS

Long-term breast cancer survivors differ in their health services use with regard to the frequency of visits as well as the health providers seen. Our results indicate the need for active surveillance through primary care providers in coordination with specialized care.

IMPLICATIONS FOR CANCER SURVIVORS

This review could help to standardize the management of breast cancer survivors and decision-makers to adapt their guidelines and clinical protocols.

Quality of diabetes care in cancer: a systematic review

PURPOSE

Overlooking other conditions during cancer could undermine gains associated with early detection and improved cancer treatment. We conducted a systematic review on the quality of diabetes care in cancer.

DATA SOURCES

Systematic searches of Medline and Embase, from 1996 to present, were conducted to identify studies on the quality of diabetes care in patients diagnosed with cancer.

STUDY SELECTION

Studies were selected if they met the following criteria: longitudinal or cross-sectional observational study; population consisted of diabetes patients; exposure consisted of cancer of any type and outcomes consisted of diabetes quality of care indicators, including healthcare visits, monitoring and testing, control of biologic parameters, or use of diabetes and other related medications.

DATA EXTRACTION

Structured data collection forms were developed to extract information on the study design and four types of quality indicators: physician visits, exams or diabetes education (collectively 'healthcare visits'); monitoring and testing; control of biologic parameters; and medication use and adherence.

RESULTS OF DATA SYNTHESIS

There were 15 studies from five countries. There was no consistent evidence that cancer was associated with fewer healthcare visits, lower monitoring and testing of biologic parameters or poorer control of biologic parameters, including glucose. However, the weight of the evidence suggests cancer was associated with lower adherence to diabetes medications and other medications, such as anti-hypertensives and cholesterol-lowering agents.

CONCLUSION

Evidence indicates cancer is associated with poorer adherence to diabetes and other medications. Further primary research could clarify cancer's impact on other diabetes quality indicators.

Health care use during cancer survivorship: Review of 5 years of evidence

Improvements in treatment strategies have resulted in increasing survival rates among patients diagnosed with cancer but also result in a growing population of individuals who have greater health care needs. These needs will persist from diagnosis throughout the continuing phase of care, or the survivorship phase. To better define models of survivorship care, there must be a strong evidence base in survivor health care use patterns. The objective of this review, which covers studies from 2012 to January 2018, was to evaluate the available evidence on patterns of health care visits among survivors of adult cancers and to understand what is known about the rate of health care visits, the physician specialties associated with these visits, and/or the types health care settings (eg, outpatient, emergency room). The findings underscore the importance of primary care, with the majority of studies reporting that >90% of survivors visited a primary care provider in the prior year. Visits to oncologists and/or other physician specialties were positively associated with receiving cancer screenings and obtaining quality care for noncancer-related conditions. High care density/low care fragmentation between physician specialties had lower costs and a lower likelihood of redundant health care utilization. The follow-up in almost all studies was 3 years, providing short-term evidence; however, as the survivorship period lengthens with improved treatments, longer follow-up will be required. The long-term patterns with which survivors of cancer engage the health care system are critical to designing long-term follow-up care plans that are effective in addressing the complex morbidity that survivors experience.

Impact of diffuse large B-cell lymphoma on visits to different provider specialties among elderly Medicare beneficiaries: challenges for care coordination

Newly diagnosed diffuse large B-cell lymphoma (DLBCL) can pose significant challenges to care coordination. We utilized a social-ecological model to understand the impact of DLBCL diagnosis on visits to primary care providers (PCPs) and specialists, a key component of care coordination, over a 3-year period of cancer diagnosis and treatment. We used hurdle models and multivariable logistic regression with the Surveillance Epidemiology and End Result-Medicare linked dataset to analyze visits to PCPs and specialists by DLBCL patients (n = 5,455) compared with noncancer patients (n = 14,770). DLBCL patients were more likely to visit PCPs (adjusted odds ratio, AOR [95% confidence interval, CI]: 1.25 [1.18, 1.31]) and had greater number of visits to PCPs (β, SE: 0.384, -0.014) than noncancer patients. Further, DLBCL patients were more likely to have any visit to cardiologists (AOR [95% CI]: 1.40 [1.32, 1.47]), endocrinologists (1.43, [1.21, 1.70]), and pulmonologists (1.51 [1.36, 1.67]) than noncancer patients. Among DLBCL patients, the number of PCP visits markedly increased during the treatment period compared with the baseline period (β, SE: 0.491, -0.028) and then decreased to baseline levels (-0.464, -0.022). Visits to PCPs and specialists were much more frequent for DLBCL patients than noncancer patients, which drastically increased during the DLBCL treatment period for chronic care. More chronic conditions, treatment side effects, and frequent testing may have increased visits to PCPs and specialists. Interventions to improve care coordination may need to target the DLBCL treatment period, when patients are most vulnerable to poor care coordination.

Quality of diabetes care in breast, colorectal, and prostate cancer

Purpose

Overlooking other medical conditions during cancer treatment and follow-up could result in excess morbidity and mortality, thereby undermining gains associated with early detection and improved treatment of cancer. We compared the quality of care for diabetes patients subsequently diagnosed with breast, colorectal, or prostate cancer to matched, diabetic non-cancer controls.

Methods

Longitudinal cohort study using primary care records from the Clinical Practice Research Datalink, United Kingdom. Patients with pre-existing diabetes were followed for up to 5 years after cancer diagnosis, or after an assigned index date (non-cancer controls). Quality of diabetes care was estimated based on Quality and Outcomes Framework indicators. Mixed effects logistic regression analyses were used to compare the unadjusted and adjusted odds of meeting quality measures between cancer patients and controls, overall and stratified by type of cancer.

Results

3382 cancer patients and 11,135 controls contributed 44,507 person-years of follow-up. In adjusted analyses, cancer patients were less likely to meet five of 14 quality measures, including: total cholesterol ≤ 5 mmol/L (odds ratio [OR] = 0.82; 95% confidence interval [CI], 0.75–0.90); glycosylated hemoglobin ≤ 59 mmol/mol (adjusted OR = 0.77; 95% CI, 0.70–0.85); and albumin creatinine ratio testing (adjusted OR = 0.83; 95% CI, 0.75–0.91). However, cancer patients were as likely as their matched controls to meet quality measures for other diabetes services, including retinal screening, foot examination, and dietary review.

Conclusions

Although in the short-term, cancer patients were less likely to achieve target thresholds for cholesterol and HbA1c, they continued to receive high-quality diabetes primary care throughout 5 years post diagnosis.

Implications for Cancer Survivors

These findings are important for cancer survivors with pre-existing diabetes because they indicate that high-quality diabetes care is maintained throughout the continuum of cancer diagnosis, treatment, and follow-up.

Electronic supplementary material

The online version of this article (10.1007/s11764-018-0717-5) contains supplementary material, which is available to authorized users.

Causes of mortality in older patients with stage 3 colon cancer

OBJECTIVES

Life expectancy plays a key role in the selection of patients with stage III colon cancer for adjuvant chemotherapy, but little is known about causes of mortality in older patients with colon cancer. We aimed to examine causes of death in this population and compare these causes between patients who received chemotherapy and those who did not. Specifically, we chose to examine the rates of death related to recurrent colon cancer versus non colon cancer.

MATERIALS AND METHODS

Patients aged 50 and older diagnosed with stage III colon cancer between 2005 and 2009 were included. Patients were divided into "younger" (aged 50-69) and "older" (aged 70+). Causes of death, which were categorized into colon cancer versus non-colon cancer related.

RESULTS

1361 patients were included, 50% of whom were 70 or older. Younger patients were more likely to receive adjuvant chemotherapy (90% vs. 60%). 601 patients died in the follow up period. Deceased patients in the younger group were more likely to die from colon cancer (81% vs. 62%). The most common cause of non-colon cancer death was other primary malignancies in younger patients and cardiovascular diseases in older patients. In older patients who received chemotherapy, 41% died; 89% of these deaths were related to colon cancer. In older patients who did not receive chemotherapy 72% died, with 38% of patients ultimately dying from colon cancer.

CONCLUSIONS

Older patients remain under-treated with chemotherapy. Although non-colon cancer deaths were more frequent in older patients with cancer, colon cancer was a still a significant cause of mortality. These deaths may be preventable with adjuvant chemotherapy.

Ten-Year Trends in Preventive Service Use Before and After Prostate Cancer Diagnosis: A Comparison with Noncancer Controls

CONTEXT

Few studies have assessed the longer-term quality of preventive care in prostate cancer (PCa) survivors.

OBJECTIVE

To compare the rates of preventive services among PCa survivors five years before and after diagnosis, to men without PCa.

DESIGN

Men enrolled in Kaiser Permanente Southern California with newly diagnosed PCa (2002-2008) were matched 1:1 to men without a PCa diagnosis on age, race, and timing of prostate-specific antigen test (N = 31,180). The use of preventive services, including colorectal cancer screening, diabetes tests, lipid panels, and influenza and pneumococcal vaccinations was assessed 5 years before and after diagnosis (or index date for controls).

MAIN OUTCOME MEASURES

Relative rates (RRs) of use were calculated for cases and controls separately and compared using Poisson regression, adjusting for comorbidities and outpatient utilization in 2014.

RESULTS

Overall, the rates of preventive services were lower among men with PCa vs men without PCa. However, in the 5 years after diagnosis, rates of preventive service use for all services were greater among PCa survivors vs men without PCa (colorectal cancer: RR = 1.05, 95% confidence interval [CI] = 1.01-1.10; lipids: RR = 1.10, 95% CI = 1.08-1.11; hemoglobin A_1C: RR = 1.17, 95% CI = 1.14-1.19; glucose: RR = 1.24, 95% CI = 1.23-1.26; influenza vaccine: RR = 1.05, 95% CI = 1.03-1.07; pneumococcal vaccine: RR = 1.03, 95% CI = 0.97-1.09).

CONCLUSION

Delivery of preventive care improved after PCa diagnosis, with survivors receiving comparable preventive care to men without PCa during the five years following diagnosis.

Most impactful factors on the health-related quality of life of a geriatric population with cancer

BACKGROUND

As the population of older adults with cancer continues to grow, the most important factors contributing to their health-related quality of life (HRQOL) remain unclear.

METHODS

A total of 1457 older adults (aged ≥65 years) with cancer participated in a telephone survey. Outcomes were measured using the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Survey (SF-12) from the Medical Outcomes Study (version 2). Statistical techniques used to identify factors in 4 domains (physical, psychological, social, and spiritual) most strongly associated with HRQOL included linear models, recursive partitioning, and random forests. Models were developed in a training data set (920 respondents) and performance was assessed in a validation data set (537 respondents).

RESULTS

Respondents were a median of 19 months from diagnosis, and 28.1% were receiving active treatment. The most relevant factors found to be associated with PCS were symptom severity, comorbidity scores, leisure-time physical activity, and having physical support needs. The most relevant factors for MCS were having emotional support needs, symptom severity score, and the number of financial hardship events. Results were consistent across modeling techniques. Symptoms found to be strongly associated with PCS included fatigue (adjusted proportion of summary score's variance [R² ] = 0.34), pain (adjusted R² = 0.32), disturbed sleep (adjusted R² = 0.16), and drowsiness (adjusted R² = 0.16). Symptoms found to be strongly associated with MCS included fatigue (adjusted R² = 0.23), problems remembering things (adjusted R² = 0.17), disturbed sleep (adjusted R² = 0.16), and lack of appetite (adjusted R² = 0.16).

CONCLUSIONS

The findings of the current study support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. A long-term comprehensive approach is needed to ensure the well-being of older adults with cancer. Cancer 2018;124:596-605. © 2017 American Cancer Society.

Patterns of Long-term Cancer Survivorship Care in a National Cancer Institute-Designated Comprehensive Cancer Center

PURPOSE

The majority of the cancer survivors in the United States are 5 or more years beyond their diagnosis. The follow-up care of these individuals remains a major concern for survivors and for the cancer care system. The purpose of this study was to characterize long-term cancer survivors' visits at a National Cancer Institute-designated comprehensive cancer center.

MATERIALS AND METHODS

We abstracted electronic medical record data for 18,882 unique patients' visits during 2010 to determine the distribution of the number of years of survival after the initial cancer diagnosis. We then reviewed 374 patient visits during a randomly selected week in April 2010 to determine whether patients were seen for treatment of a new diagnosis of cancer, a residual or recurrent cancer, for a second or secondary cancer, or for cancer survivorship care while not actively receiving treatment (other than adjuvant hormonal therapy).

RESULTS

In the 1-year group of 18,882 unique patients visits the percentage of patients who were <1, 1 to 5, 6 to 10, and >10 years postdiagnosis were 18.7%, 48.7%, 18.9%, and 13.8%, respectively. During the selected week, 74% of the total office visits were with patients who were being actively treated for a new cancer, relapse, or a second cancer, whereas 24% were not being seen for treatment of an active malignancy. The percentage of total office visits with patients who were <6, 6 to 10, or >10 years postdiagnosis and had completed their initial treatment were 21.4%, 3.7%, and 1%, respectively. Approximately 5% of oncology office visits were with cancer survivors who were 5 or more years postdiagnosis and not receiving treatment.

CONCLUSIONS

In a database of over 18,000 unique patients who were seen at a major cancer center in 2010, approximately 68% were 5 or less and 32% were 6 or more years postdiagnosis. A review of the medical oncology notes in a random sample of cases of oncology visits demonstrated that approximately 5% of office visits were with long-term cancer survivors who were >5 years postdiagnosis and not receiving active treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors often indicate a preference to receive long-term follow-up care from their oncologist. These findings suggest that long-term cancer survivorship care represents only a small component of care at a comprehensive cancer center and also that alternative models for long-term survivorship health care need to be considered.

Racial disparities in the utilization of preventive health services among older women with early-stage endometrial cancer enrolled in Medicare

To assess differences in the receipt of preventive health services by race/ethnicity among older women with endometrial cancer enrolled in Medicare, we conducted a retrospective population-based cohort study of women diagnosed with endometrial cancer from 2001 to 2011 in the Surveillance Epidemiology and End Results (SEER)-Medicare database. Women with stage I or II endometrial cancer of epithelial origin were included. The exposure was race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, and NH Asian/Pacific Islander [PI]). The services examined were receipt of influenza vaccination and screening tests for diabetes mellitus, hyperlipidemia, and breast cancer. We used multivariate logistic regression to estimate odds ratios with 95% confidence intervals (CI) adjusted for age, region, and year of diagnosis. A total of 13,054 women were included. In the 2 years after diagnosis, receipt of any influenza vaccine ranged from 45% among NH Black women to 67% among NH White women; receipt of a mammogram ranged from 65% among NH Black women to 74% among NH White women. Relative to NH White women, NH Black women had a lower likelihood of receiving both influenza vaccination (adjusted odds ratio [aOR] 0.40, 95% CI 0.33-0.44) and screening mammography (aOR 0.64, 95% CI 0.52-0.79). Hispanic women also were less likely to receive influenza vaccination than NH White women (aOR 0.61, 95% CI 0.51-0.72). There were no significant differences across racial groups for diabetes or cholesterol screening services. Among older women with early-stage endometrial cancer, racial disparities exist in the utilization of some preventive services.

Outcomes of preexisting diabetes mellitus in breast, colorectal, and prostate cancer

Purpose

Preexisting diabetes is associated with increased morbidity and mortality in cancer. We examined the impact of incident cancer on the long-term outcomes of diabetes.

Methods

Using the United Kingdom Clinical Practice Research Datalink, we identified three cohorts of diabetes patients subsequently diagnosed with breast, colorectal, or prostate cancer, each matched to diabetic noncancer controls. Patients were required to have survived at least 1 year after cancer diagnosis (cases) or a matched index date (controls), and were followed up to 10 years for incident microvascular and macrovascular complications and mortality. Multivariate competing risks regression analyses were used to compare outcomes between cancer patients and controls.

Results

Overall, there were 3382 cancer patients and 11,135 controls with 59,431 person-years of follow-up. In adjusted analyses, there were no statistically significant (p ≤ 0.05) differences in diabetes complication rates between cancer patients and their controls in any of the three cancer cohorts. Combined, cancer patients were less likely (adjusted hazard ratio [HR] 0.88; 95% CI = 0.79–0.98) to develop retinopathy. Cancer patients were more likely to die of any cause (including cancer), but prostate cancer patients were less likely to die of causes associated with diabetes (HR 0.61; 95% CI = 0.43–0.88).

Conclusions and implications

There is no evidence that incident cancer had an adverse impact on the long-term outcomes of preexisting diabetes.

Implications for Cancer Survivors

These findings are important for cancer survivors with preexisting diabetes because they suggest that substantial improvements in the relative survival of several of the most common types of cancer are not undermined by excess diabetes morbidity and mortality.

Defining cancer survivors, their needs, and perspectives on survivorship health care in the USA

More people are living after a diagnosis of cancer than ever before and now account for around 5% of the US population. The specialty of cancer survivorship has been developing and growing since the mid-1980s, but the term survivor is open to debate by people living with cancer and those caring for them. Regardless of the term used, many ongoing physical, psychological, and social needs affect quality of life for people who are living with cancer and those who have survived the disease. Survivors prefer to have these needs addressed by their oncologist but also want their primary care provider to have a role. However, survivors also believe there are communication and coordination barriers between care providers. The existing method for delivering cancer care is becoming unsustainable and is not adequately configured to deliver high-quality cancer care to this growing population in the USA, especially when confronted with projected health-care shortages by 2020. In this Series paper, we define the term cancer survivor, discuss survivors' ongoing needs and preferences for care over time, and consider the implications for delivering coordinated cancer care in the USA.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

Relationship Between Quality of Comorbid Condition Care and Costs for Cancer Survivors

PURPOSE

To estimate the association between cancer survivors' comorbid condition care quality and costs; to determine whether the association differs between cancer survivors and other patients.

METHODS

Using the SEER-Medicare-linked database, we identified survivors of breast, prostate, and colorectal cancers who were diagnosed in 2004, enrolled in Medicare fee-for-service for at least 12 months before diagnosis, and survived ≥ 3 years. Quality of care was assessed using nine process indicators for chronic conditions, and a composite indicator representing seven avoidable outcomes. Total costs on the basis of Medicare amount paid were grouped as inpatient and outpatient. We examined the association between care quality and costs for cancer survivors, and compared this association among 2:1 frequency-matched noncancer controls, using comparisons of means and generalized linear regressions.

RESULTS

Our sample included 8,661 cancer survivors and 17,332 matched noncancer controls. Receipt of recommended care was associated with higher outpatient costs for eight indicators, and higher inpatient and total costs for five indicators. For three measures (visit every 6 months for patients with chronic obstructive pulmonary disease or diabetes, and glycosylated hemoglobin or fructosamine every 6 months for patients with diabetes), costs for cancer survivors who received recommended care increased less than for noncancer controls. The absence of avoidable events was associated with lower costs of each type. An annual eye examination for patients with diabetes was associated with lower inpatient costs.

CONCLUSION

Higher-quality processes of care may not reduce short-term costs, but the prevention of avoidable outcomes reduces costs. The association between quality and cost was similar for cancer survivors and noncancer controls.

Effect of Comorbidity on Postoperative Survival Outcomes in Patients with Solid Cancers: A 6-Year Multicenter Study in Taiwan

Purpose: Patients with comorbidities are more likely to experience treatment-related toxicities and death. Our aim was to examine the effect of comorbidity on postoperative survival outcomes in patients with solid cancers.

Methods: In total, 37,288 patients who underwent potentially curative operations for solid cancers at four affiliated hospitals of the Chang Gung Memorial Hospital, between 2007 and 2012, were stratified according to the Charlson Comorbidity Index (CCI) for postoperative survival analysis. Multivariate Cox regression was used to adjust hazard ratios of survival outcomes among different CCI subgroups.

Results: A significantly greater proportion of patients with comorbidities presented with poorer clinicopathological characteristics compared to those without. After cancer surgery, 26% of patients died after a median follow-up duration of 38.9 months. Overall mortality rates of patients with CCI scores of 0, 1, 2, 3, 4, and 5-8 were 22.9%, 29.5%, 38.2%, 43.2%, 50.2%, and 56.4%, respectively. After adjusting for other clinicopathological factors, patients with increasing CCI scores were associated with significantly reduced overall and noncancer-specific survival rates, while only patients with CCI scores of >2 were associated with higher cancer-specific mortality rates.

Conclusions: Patients with increasing numbers of comorbidities were associated with reduced postoperative survival outcomes. Patients with multiple comorbidities were most vulnerable to both cancer- and noncancer-specific deaths in the first 6 months after cancer surgery. Our results suggest that for both the patient and clinician, it should be taken into consideration about cancer surgery when dealing with multiple comorbidities.

How are spousal depressed mood, distress, and quality of life associated with risk of depressed mood in cancer survivors? Longitudinal findings from a national sample

BACKGROUND

Spouses of cancer survivors experience both positive and negative effects from caregiving. However, it is less clear what role spousal well-being may have on cancer survivors. This study aimed to determine the impact of spousal psychosocial factors on survivor depressed mood and whether this association differed by gender.

METHODS

We examined longitudinal data on cancer survivors and their spouses (n = 910 dyads) from the 2004-2012 Medical Expenditures Panel Survey and a matched sample of cancer-free dyads. Subjects reported depressed mood, psychologic distress, and mental and physical health-related quality of life (HRQoL) at two time points (T1/T2). Dyadic multilevel models evaluated the impact of psychosocial factors at T1 on depressed mood at T2, controlling for sociodemographics, cancer type, survivor treatment status, and depressed mood at T1.

RESULTS

Cancer survivors whose spouses reported depressed mood at T1 were 4.27 times more likely to report depressed mood at T2 [95% confidence interval (CI), 2.01-9.07]; this was stronger for female survivors (OR, 9.49; 95% CI, 2.42-37.20). Better spousal mental and physical HRQoL at T1 were associated with a 30% decrease in survivor depressed mood risk at T2. Most spillover effects were not observed in comparison dyads.

CONCLUSION

Depressed mood and poor HRQoL in spouses may increase the risk of depressed mood in cancer survivors. The risk may be especially strong for female survivors.

IMPACT

Identifying and improving spousal mental health and HRQoL problems may reduce the risk of depressed mood in cancer survivors. Future research should examine whether incorporating spousal care into psychooncology and survivorship programs improves survivor outcomes.

Impact of Prostate Cancer Diagnosis on Noncancer Hospitalizations Among Elderly Medicare Beneficiaries With Incident Prostate Cancer

OBJECTIVES

The purpose of this study was to analyze the impact of cancer diagnosis on noncancer hospitalizations (NCHs) by comparing these hospitalizations between the precancer and postcancer periods in a cohort of fee-for-service Medicare beneficiaries with incident prostate cancer.

METHODS

A population-based retrospective cohort study was conducted using the SEER-Medicare linked database for 2000 through 2010. The study cohort consisted of 57,489 elderly men (aged ≥ 67 years) with incident prostate cancer. NCHs were identified in 6 periods (t1-t6) before and after the incidence of prostate cancer. Each period consisted of 120 days. For each period, NCHs were defined as inpatient admissions with primary diagnosis codes not related to prostate cancer, prostate cancer-related procedures, or bowel, sexual, and urinary dysfunction. Bivariate and multivariate comparisons on rates of NCHs between the precancer and postcancer periods accounted for the repeated measures design.

RESULTS

The rate of NCHs was higher during the postcancer period (5.1%) compared with the precancer period (3.2%). In both unadjusted and adjusted models, elderly men were 37% (odds ratio [OR], 1.37; 95% CI, 1.32, 1.41) and 38% (adjusted OR, 1.38; 95% CI, 1.33, 1.46) more likely to have any NCHs during the postcancer period compared with the precancer period.

CONCLUSIONS

Elderly men with prostate cancer had a significant increase in the risk of NCHs after the diagnosis of prostate cancer. This study highlights the need to design interventions for reducing the excess NCHs after prostate cancer diagnosis among elderly men.

ReCAP: ASCO Core Curriculum for Cancer Survivorship Education

CONTEXT AND QUESTION(S) ASKED:

The number of cancer survivors is increasing exponentially. Currently there about 15 million cancer survivors, and by 2025, there will be nearly 20 million. Who will provide survivorship care, what are evidenced-based or best care practices, what are best methods to disseminate this information and assess its impact on physician practice, and what are the most cost-effective health care delivery models to serve the majority of survivors?

SUMMARY ANSWER:

The ASCO Survivorship Committee in collaboration with the ASCO Professional Development Committee developed a core curriculum and core competencies for physicians, allied health professionals, training programs, and policymaking organizations. Adapted from Institute of Medicine recommendations for survivorship care, the core curriculum and competencies include the following subheadings: surveillance for recurrence and second malignancies, long-term and late effects, health promotion and prevention, psychosocial well-being, special populations including adolescent and young adult survivors, older adult cancer survivors, caregivers of cancer survivors and communication and care coordination.

METHODS:

An environmental scan (a process that systematically surveys and interprets relevant data to identify opportunities and barriers) for survivorship was performed. Although survivorship content exists in various courses, conferences, guidelines, and Web-based applications, the information is incomplete and not easily found. Hence, there was a need for this content to be easy to access and available in one place. Content experts formulated the individual sections based on the environmental scan and their knowledge of the various subheadings.

BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:

Both an environmental scan and a comprehensive literature review have standard methodologies. The differences are in scope; an environmental scan is more like an overview, and the standard literature review is more granular. For this article, we felt that environmental scan better served the purpose of developing a survivorship core curriculum and competencies.

REAL-LIFE IMPLICATIONS:

Survivorship care is one the most challenging problems oncologists face today and in the near future. Fundamental to the relatively new field of survivorship care is this core curriculum and competencies, which provide the framework necessary to generate appropriate referrals depending on local practices and expertise.

Prevention, Detection, and Management of Chemotherapy-Related Cardiac Dysfunction

Cancer treatment-related cardiac dysfunction (CTRCD) occurs with many agents used in the treatment of cancer. This is most relevant in patients receiving cancer treatment with curative intent as opposed to those treated with a palliative intent where lifespan is more likely to be limited by the cancer diagnosis. Clinicians need to be aware of methods to prevent, detect, and manage CTRCD. This article frames an approach to CTCRD based on the American College of Cardiology/American Heart Association stages of heart failure (HF). In patients who are at risk for CTRCD (stage A HF), risk reduction methods may be warranted, including management of cardiovascular risk factors, modification of cancer treatment, and universal preventive therapy. Once cancer therapy begins, it is prudent to detect and promptly treat myocardial dysfunction (stage B HF). This can be achieved by careful monitoring during therapy using echocardiography, multigated acquisition scans, or cardiac MRI. Subclinical myocardial systolic dysfunction (ie, without a drop in ejection fraction) can be identified using either echocardiography measured peak systolic global longitudinal strain or cardiac troponin I. At present, there is insufficient evidence to institute preventive interventions based on changes in these preclinical markers. Finally, in patients with stage C/D HF, management strategies should follow existing guidelines. Advanced treatment including cardiac transplantation and mechanical circulatory support may be considered in appropriate circumstances.

Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination

PURPOSE

The purpose of this study is to investigate provider specialty, care coordination, and cancer survivors' comorbid condition care.

METHODS

This retrospective cross-sectional Surveillance, Epidemiology, and End Results (SEER)-Medicare study included cancer survivors diagnosed in 2004, 2-3 years post-cancer diagnosis, in fee-for-service Medicare. We examined (1) provider specialties (primary care providers (PCPs), oncology specialists, other specialists) visited post-hospitalization, (2) role of provider specialties in chronic and acute condition management, and (3) an ambulatory care coordination measure. Outcome measures covered (1) visits post-hospitalization for nine conditions, (2) chronic disease management (lipid profile, diabetic eye exam, diabetic monitoring), and (3) acute condition management (electrocardiogram (EKG) for congestive heart failure (CHF), imaging for CHF, EKG for transient ischemic attack, cholecystectomy, hip fracture repair).

RESULTS

Among 8661 cancer survivors, patients were more likely to visit PCPs than oncologists or other specialists following hospitalizations for 8/9 conditions. Patients visiting a PCP (vs. not) were more likely to receive recommended care for 3/3 chronic and 1/5 acute condition indicators. Patients visiting a nother specialist (vs. not) were more likely to receive recommended care for 3/3 chronic and 2/5 acute condition indicators. Patients visiting an oncology specialist (vs. not) were more likely to receive recommended care on 2/3 chronic indicators and less likely to receive recommended care on 1/5 acute indicators. Patients at greatest risk for poor coordination were more likely to receive appropriate care on 4/6 indicators.

CONCLUSIONS

PCPs are central to cancer survivors' non-cancer comorbid condition care quality. Implications for Cancer Survivors PCP involvement in cancer survivors' care should be promoted.

Risk of Ischemic Stroke in Patients With Gastric Cancer: A Nationwide Population-Based Cohort Study

Improvements in therapeutic modalities have prolonged the survival of gastric cancer patients. Comorbidities such as thromboembolic events that emerge as a result of disease complexities and/or treatments received have not been considered. The objectives of this study are to examine the relationship between gastric cancer and ischemic stroke, and to determine predictive risk factors. A nationwide population-based cohort study was conducted using data from the Taiwan National Health Insurance database. A total of 45,060 gastric cancer patients and non-cancer counterparts without antecedent stroke were recruited. Hazard ratios (HRs) and the cumulative incidence of ischemic stroke were calculated, and risk factors for ischemic stroke were assessed. Gastric cancer patients were associated with higher risk of ischemic stroke (HR 1.11, 95% confidence interval [CI] 1.03-1.19, P = 0.007), especially in participants younger than 65 years (HR 1.61, 95% CI 1.39-1.86, P < 0.001) and in female participants (HR 1.30, 95% CI 1.14-1.49; P < 0.001) when compared with the matched cohort. Independent risk factors of ischemic stroke in gastric cancer patients included age, hypertension, atrial fibrillation, dyslipidemia, and having received major surgery for gastric cancer. Our findings suggest the importance of stroke surveillance and prevention strategies in high-risk patients. Having received major surgery for gastric cancer is a significant risk factor in these patients.

Changes in Medication Management After a Diagnosis of Cancer Among Medicare Beneficiaries With Diabetes

PURPOSE

A new cancer diagnosis commonly initiates a cascade of health care decisions that have potentially important consequences for management of other chronic conditions such as diabetes. We sought to determine whether a new cancer diagnosis is associated with changes in medication adherence among Medicare beneficiaries with diabetes, and whether the relationship is affected by life expectancy and generosity of drug coverage.

METHODS

The study population was drawn from a 5% random sample of Medicare beneficiaries with diabetes enrolled in Medicare Part D in 2007 and 2008. Patients had cancer newly diagnosed between January and December 2007 (n = 4,348) and were compared with a cancer-free control group (N = 28,507) assigned a pseudo-diagnosis date. Adherence (proportion of days covered [PDC]) with oral hypoglycemic agents, renin-angiotensin-aldosterone system inhibitors, and statins was tracked for 6 months before and after the diagnosis date. Multivariable regression models assessed the independent impact of a cancer diagnosis, life expectancy (proxy measure: died 7 to 12 months after index date), and coverage generosity (proxy measure: low-income subsidy recipient) on PDC, controlling for individual characteristics.

RESULTS

Relatively larger declines in medication adherence (3 to 5 percentage points; P < .001) were observed overall for patients with cancer versus controls. Short life expectancy was associated with between 8% and 11% lower PDC (P < .001) in the cancer subgroup relative to controls. Low-income subsidy status had no differential effect on changes in drug adherence.

CONCLUSION

A cancer diagnosis among patients with diabetes reduced adherence with evidence-based medications, particularly if patients' life expectancy was short.

Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into "regular life." This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of patients achieves optimal outcomes.