Identifying and characterizing cancer survivors in the US primary care safety net

A comparison of chronic conditions and health characteristics between cancer survivors and non-cancer survivors

OBJECTIVE

Cancer survivors have unique healthcare needs. An important consideration for survivorship is chronic diseases and health risk factors. The purpose of this study is to describe demographics, risk factors, and comorbid health conditions in adult cancer survivors.

METHOD

We analyzed 2019 Arizona Behavioral Risk Factor Surveillance System data to compare cancer survivors to non-cancer survivors (aged 18 or older) to assess differences between the two populations. Adjusted and unadjusted population-based estimates and 95% confidence intervals were calculated, and multivariable logistic regression models were performed.

RESULTS

Eight thousand nine-hundred and twenty (8920) respondents (1007 survivors; 7913 non-cancer survivors) were included. Compared to non-cancer survivors, cancer survivors were more likely to be female, 65 years and older, non-Hispanic white, veterans, and less likely to be employed. Survivors had higher rates of coronary heart disease, stroke, chronic obstructive pulmonary disease, kidney disease, hypertension, arthritis, multiple chronic conditions, being overweight, and being a former smoker. Survivors were more likely to report fair/poor health than non-cancer survivors.

DISCUSSION

These findings can be used by healthcare and public health practitioners to evaluate the programmatic efforts and resources, implement targeted interventions toward cancer survivors, and improve health and quality of life.

Research-practice partnership: supporting rural cancer survivors in Montana

The objective of this Research-Practice Partnership was to disseminate and implement strategies to assist Community Health Centers in improving the care of rural cancer survivors in Montana. Funded by the National Cancer Institute's Community Outreach and Engagement mechanism, this project utilized the MAP-IT (Mobilize, Assess, Plan, Implement, Track) program planning framework from Healthy People 2020. Partners included Montana's Department of Public Health and Human Services' Cancer Control Program, Montana Primary Care Association, One Health Community Health Center, and Huntsman Cancer Institute at the University of Utah. Project activities focused on (1) Planning, creating, implementing, and evaluating provider/care team education sessions through the Project ECHO tele-mentoring platform and through short webinars and (2) Building processes for identifying, documenting, and connecting with survivors using electronic health records (EHRs) and other resources. Lessons learned from this project include the value of aligning partner goals from the outset to foster sustained commitment, the importance of adapting implementation plans to address challenges and leverage opportunities, and the need for accurate EHR data and formal processes for identifying and engaging with cancer survivors.

Importance of primary care for underserved cancer patients with multiple chronic conditions

PURPOSE

To understand the impact of pre-existing conditions on healthcare utilization among under- and uninsured patients in the transition from cancer treatment to post-treatment survivorship.

METHODS

Using electronic health record data, we constructed a cohort of patients seen in an integrated county health system between 1/1/2010 and 12/31/2016. Six hundred thirty-one adult patients diagnosed with non-metastatic breast or colorectal cancer during this period (cases) were matched 1:1 on sex and Charlson comorbidity index to non-cancer patients who had at least two chronic conditions and with at least one visit to the health system during the study period (controls). Conditional fixed effects Poisson regression models compared number of primary care and emergency department (ED) visits and completed [vs. no show or missed] appointments between cancer and non-cancer patients.

RESULTS

Cancer patients had significantly lower number of visits compared with non-cancer patients (N = 46,965 vs. 85,038). Cancer patients were less likely to have primary care (IRR = 0.25; 95% CI: 0.24, 0.27) and ED visits (IRR = 0.57; 95% CI: 0.50, 0.64) but more likely to complete a scheduled appointment (AOR = 4.83; 95% CI: 4.32, 5.39) compared with non-cancer patients. Cancer patients seen in primary care at a higher rate were more likely to visit the ED (IRR = 2.06; 95% CI: 1.52, 2.80) than those seen in primary care at a lower rate.

CONCLUSION

Health systems need to find innovative, effective solutions to increase primary care utilization among cancer patients with chronic care conditions to ensure optimal management of both chronic conditions and cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Maintaining regular connections with primary care providers during active cancer treatment should be promoted.

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.

Healthcare utilization trajectory among survivors of colorectal cancer

PURPOSE

To examine healthcare utilization patterns among patients < 65 y with colorectal cancer (CRC) from pre-diagnosis to 3 y into survivorship.

METHODS

Truven Health Analytics MarketScan Commercial Claims and Encounters Database was used to identify patients diagnosed with non-metastatic CRC between 2014 and 2016, with follow-up until 12/31/2019. Total visits (inpatient and outpatient) were estimated for 6 months intervals from 2 y to 1 months prior to CRC diagnosis (pre-cancer phase) and from a 1-y post-cancer diagnosis to a 3-y post-cancer diagnosis (survivorship phase). Utilization patterns from pre- to post-diagnosis were defined using median and 75th percentile visit counts. Interrupted time series (ITS) analyses examined pre- and post-cancer diagnosis utilization trends. Multivariable regression models estimated pre-cancer factors associated with high and low utilization patterns.

RESULTS

Median age at CRC was 54 y (21-62); 50.6% of the patients were male, 30.9% were diagnosed with rectal cancer. ITS analyses demonstrated four utilization patterns with distinct pre- and post-cancer diagnosis utilization trends. Rectal cancer (RR = 1.13, p < 0.001) and high pre-cancer utilization (RR = 2.05, p < 0.001) were associated with a greater risk of high survivor phase utilization. Gastrointestinal conditions accounted for the greatest proportion of visits in pre-cancer phase (18%) and survivorship (17%), followed by cardiovascular disease (10% and 8%).

CONCLUSIONS

Distinct patterns of healthcare utilization are observed both in the pre-cancer phase and survivorship phase of colorectal cancer and are influenced by cancer location, age, therapeutic exposures, and prior healthcare needs.

IMPLICATIONS FOR CANCER SURVIVORS

Not all patients will require the same level or type of long-term follow-up. Identifying indication-specific healthcare utilization patterns that provide evidence for risk stratification may facilitate a more patient-centric and economically sustainable way to deliver care.

Clinicians' experiences with cancer patients living longer with incurable cancer: a focus group study in the Netherlands

AIM

To explore (1) experiences of primary care physicians (PCPs) and oncological medical specialists about providing care to patients living longer with incurable cancer, and (2) their preferences concerning different care approaches (palliative support, psychological/survivorship care support).

BACKGROUND

At present, oncological medical specialists as well as PCPs are exploring how to improve and better tailor care to patients living longer with incurable cancer. Our previous study at the in-patient oncology unit showed that patients living longer with incurable cancer experience problems in how to deal with a prognosis that is insecure and fluctuating. To date, it could be argued that treating these patients can be done with a 'palliative care' or a 'survivorship/psychosocial care' approach. It is unknown what happens in actual medical practice.

METHODS

We performed multidisciplinary group meetings: 6 focus groups (3 homogenous groups with PCPs (n = 15) and 3 multidisciplinary groups (n = 17 PCPs and n = 6 medical specialists) across different parts of the Netherlands. Qualitative data were analysed with thematic analysis.

FINDINGS AND CONCLUSIONS

In the near future, PCPs will have an increasing number of patients living longer with incurable cancer. However, in a single PCP practice, the experience with incurable cancer patients remains low, partly because patients often prefer to stay in contact with their medical specialist. PCPs as well as medical specialists show concerns in how they can address this disease phase with the right care approach, including the appropriate label (e.g. palliative, chronic, etc.). They all preferred to be in contact early in the disease process, to be able to discuss and take care for the patients' physical and psychological well-being. Medical specialists can have an important role by timely referring their patients to their PCPs. Moreover, the disease label 'chronic' can possibly assist patients to live their life in the best possible way.

Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers

BACKGROUND

Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs).

OBJECTIVE

To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period.

DESIGN

A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns.

PARTICIPANTS

The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019.

MAIN MEASURES

Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke.

KEY RESULTS

Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years.

CONCLUSIONS

CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.

Healthcare utilization in cancer survivors: six-month longitudinal cohort data

PURPOSE

To describe healthcare utilization and reasons for delaying medical care and to identify factors that influence high healthcare utilization and care delay among cancer survivors.

METHODS

Baseline (n = 991) and 6 month follow-up data (n = 777) were collected among breast, prostate, and colorectal cancer survivors from 32 US cancer centers. Participants completed surveys on healthcare utilization (e.g., number of visits to specific providers) and delay of medical care. We categorized participants as high or low users based on median number of visits. We used logistic regression models to examine factors that predicted high healthcare utilization or delay.

RESULTS

Survivors reported a median of 10.5 visits to healthcare providers and 28% reported ever delaying medical care over 6 months. Compared to prostate cancer survivors, breast and colorectal survivors were 2.4 times more likely (CI = 1.2-4.8) and 4 times more likely (CI = 2.2-7.3) to be high healthcare users, respectively. A higher quality of life score predicted high healthcare utilization (OR = 2.4, CI = 2.0-2.8) and delay of medical care (OR = 1.8, CI = 1.5-2.2). Black survivors were 1.5 times more likely than White survivors to be high healthcare users (CI = 1.1-2.0) and respondents reporting a race category other than White or Black were 1.8 times more likely to delay care (CI = 1.3-2.5). Lower levels of self-efficacy predicted greater healthcare use (OR = 0.7, CI = 0.6-0.8) and delay (OR = 0.6, CI = 0.5-0.7).

CONCLUSION

Our findings suggest that race, education, marital status, cancer type, time since diagnosis, quality of life, and self-efficacy are associated with both high healthcare utilization and delay among cancer survivors.

Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies

CONTEXT

Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear.

OBJECTIVES

To provide an evidence synthesis.

METHODS

We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods.

RESULTS

Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14).

CONCLUSIONS

We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors

Background

There is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics.

Methods

Data were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines.

Results

Out of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10–6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30–3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62–1.58).

Conclusions

Uninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

Assessing Cancer History Accuracy in Primary Care Electronic Health Records Through Cancer Registry Linkage

BACKGROUND

Many cancer survivors receive primary care in community health centers (CHCs). Cancer history is an important factor to consider in the provision of primary care, yet little is known about the completeness or accuracy of cancer history data contained in CHC electronic health records (EHRs).

METHODS

We probabilistically linked EHR data from more than1.5 million adult CHC patients to state cancer registries in California, Oregon, and Washington and estimated measures of agreement (eg, kappa, sensitivity, specificity). We compared demographic and clinical characteristics of cancer patients as estimated by each data source, evaluating distributional differences with absolute standardized mean differences.

RESULTS

A total 74 707 cancer patients were identified between the 2 sources (EHR only, n = 22 730; registry only, n = 23 616; both, n = 28 361). Nearly one-half of cancer patients identified in registries were missing cancer documentation in the EHR. Overall agreement of cancer ascertainment in the EHR vs cancer registries (gold standard) was moderate (kappa = 0.535). Cancer site-specific agreement ranged from substantial (eg, prostate and female breast; kappa > 0.60) to fair (melanoma and cervix; kappa < 0.40). Comparing population characteristics of cancer patients as ascertained from each data source, groups were similar for sex, age, and federal poverty level, but EHR-recorded cases showed greater medical complexity than those ascertained from cancer registries.

CONCLUSIONS

Agreement between EHR and cancer registry data was moderate and varied by cancer site. These findings suggest the need for strategies to improve capture of cancer history information in CHC EHRs to ensure adequate delivery of care and optimal health outcomes for cancer survivors.

Variations in Long-term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000-2019)

Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.

The Affordable Care Act improved health insurance coverage and cardiovascular-related screening rates for cancer survivors seen in community health centers

Background

This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular‐related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low‐density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs).

Methods

This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre‐ACA time period and 2 post‐ACA time periods were assessed.

Results

The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012‐2013 to 4.5%in 2016‐2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012‐2013 to 22.5% in 2016‐2017). Cardiovascular‐related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre‐ACA period (2012‐2013) to the post‐ACA period (2016‐2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%).

Conclusions

This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular‐related preventive screening rates for cancer survivors seen in CHCs.

The Affordable Care Act (ACA) provides coverage options for cancer survivors seen in community health centers, especially in states that have expanded Medicaid; unfortunately, 1 in 5 cancer survivors living in a state that has not expanded Medicaid coverage eligibility remains uninsured. The ACA Medicaid expansion provision change, likely in tandem with other ACA changes, has also contributed to modest improvements in rates of cardiovascular‐related screenings for cancer survivors.