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Forster M, Deal AM, Page A, Vohra S, Wardell AC, Pak J, Lund JL, Nyrop KA, Muss HB. Dose delay, dose reduction, and early treatment discontinuation in Black and White women receiving chemotherapy for nonmetastatic breast cancer. Oncologist 2024:oyae150. [PMID: 38913986 DOI: 10.1093/oncolo/oyae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND To describe reasons for deviations from planned chemotherapy treatments in women with nonmetastatic breast cancer that contribute to less-than-planned receipt of chemotherapy. METHODS Electronic medical records for patients receiving chemotherapy were reviewed for adverse events and treatment modifications. Log-binomial regression models were used to estimate relative risks (RRs) with 95% CIs to examine associations between chemotherapy modifications, patient characteristics, and treatment modalities. RESULTS Delays in chemotherapy initiation (7%) were for surgical complications (58%), personal reasons (16%), and other (26%; port malfunction, infections, and obtaining extra imaging). Delays during chemotherapy (38%) were for infections (20%), neutropenia (13%), and personal reasons (13%). Dose reductions (38%) were for neuropathy (36%), unknown causes (9%), anemia (9%), and neutropenia (8%). Early treatment discontinuations (23%) were for neuropathy (29%). Patients receiving paclitaxel/nab-paclitaxel (RR 2.05; 95% CI, 1.47-2.87) and an anthracycline (RR 1.89; 95% CI, 1.39-2.57) reported more dose delays during chemotherapy. Black race (RR 1.46; 95% CI, 1.07-2.00), stage 3 (RR 1.79; 95% CI, 1.09-2.93), and paclitaxel/nab-paclitaxel receipt (RR 1.39; 95% CI, 1.02-1.90) increased the likelihood of dose reduction. Both Black race (RR 2.06; 95% CI, 1.35-3.15) and receipt of paclitaxel/nab-paclitaxel (RR 1.93; 95% CI, 1.19-3.13) increased the likelihood of early discontinuation. Patients receiving anthracyclines had higher rates of hospitalizations during chemotherapy (RR: 1.79; 95% CI, 1.11-2.89). CONCLUSION Toxicities are the most common reason for treatment modifications and need close monitoring in high-risk groups for timely intervention. Dose reductions and early treatment discontinuations occurred more for Black patients and need further study.
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Affiliation(s)
- Moriah Forster
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University, Nashville, TN 37232, United States
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Annie Page
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Sanah Vohra
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Alexis C Wardell
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Joyce Pak
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Jennifer L Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Kirsten A Nyrop
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Hyman B Muss
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, United States
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
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Slejko JF, Rueda JD, Trovato JA, Gorman EF, Betz G, Arcona S, Zacker C, Stuart B. A Comprehensive Review of Methods to Measure Oral Oncolytic Dose Intensity Using Retrospective Data. J Manag Care Spec Pharm 2019; 25:1125-1132. [PMID: 31556821 PMCID: PMC10398302 DOI: 10.18553/jmcp.2019.25.10.1125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Understanding the real-world use of oral oncolytics is essential to assess drug effectiveness. Retrospective analyses using medical and pharmacy claims data allow observation of drug use patterns and health outcomes. However, studies of medication adherence to oral oncolytics may not be sufficient in characterizing exposure because they typically measure refill frequency, not the administered dose or dose changes. Patients who appear fully adherent by traditional measures may be receiving different doses and experiencing differing effectiveness. Relative dose intensity (RDI) is a measure that has been used for intravenous drugs to capture the amount of a particular chemotherapeutic agent administered per unit of time (dose intensity), expressed as the fraction of the amount recommended in evidence-based guidelines. Such a measure would be useful for real-world studies of comparative effectiveness to characterize patient exposure to oral oncolytics. OBJECTIVE To identify studies that used administrative claims data to measure real-world oral oncolytic dose intensity, RDI, or similar constructs. METHODS Two health sciences librarians conducted a literature search (PubMed, January 1, 1809-February 6, 2018) including terms in each of the following concept areas: oncology drugs, dosage, and retrospective data sources. At least 2 reviewers scanned each title and abstract of publications retrieved from PubMed. Abstracts that indicated the study reported dose or related concepts and oral oncolytics using retrospective data sources were marked for full-text review. During full-text review, papers were excluded if they did not study oral oncolytics (i.e., only described intravenous chemotherapy); if they did not report drug dosage; or if the study was not retrospective. Resulting studies were included for full-text data extraction. RESULTS Of the 1,640 publications returned from the search, 41 were marked for full-text review. Full-text review established that 17 studies addressed a concept related to dose of oral oncolytics using retrospective data. Twenty-four studies were excluded: 11 did not measure dose; 9 did not study oral oncolytics; and 4 were not retrospective studies. Among the 17 articles marked for extraction, 5 articles reported dose intensity or RDI using medical records or electronic health record (EHR) data. CONCLUSIONS This study reveals not only the need for a claims-based measure of dose intensity for oral oncolytics, but also provides a basis for the development of such a measure based on previous EHR-based studies. While several claims data studies have characterized oral oncolytic dosing and duration, we found that no studies combined these dimensions into a single measure such as dose intensity. Methods using EHR data may be translatable to a claims data study. Future research is needed to develop and validate such measures. DISCLOSURES Novartis Pharmaceuticals provided funding for this study and is a manufacturer of oral onalytics, which is under study in this article. Arcona and Zacker are employees of Novartis. Slejko reports grants from PhRMA, PhRMA Foundation, and Takeda Pharmaceuticals and consulting fees from Pfizer, outside the submitted work. Stuart reports consulting fees from the University of Maryland during the study. The other authors have nothing to disclose. The preliminary findings of this study were presented in a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL.
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Affiliation(s)
- Julia F Slejko
- Department of Pharmaceutical Health Services, University of Maryland School of Pharmacy, Baltimore
| | - Juan-David Rueda
- Department of Pharmaceutical Health Services, University of Maryland School of Pharmacy, Baltimore
| | - James A Trovato
- Department of Pharmaceutical Health Services, University of Maryland School of Pharmacy, Baltimore
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore
| | - Gail Betz
- Health Sciences and Human Services Library, University of Maryland, Baltimore
| | | | | | - Bruce Stuart
- Department of Pharmaceutical Health Services, University of Maryland School of Pharmacy, Baltimore
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Spronk PER, de Ligt KM, van Bommel ACM, Siesling S, Smorenburg CH, Vrancken Peeters MTFD. Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts' experiences in the Netherlands. PATIENT EDUCATION AND COUNSELING 2018; 101:2111-2115. [PMID: 30054106 DOI: 10.1016/j.pec.2018.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer. METHODS Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC. RESULTS A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%). CONCLUSION This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making.
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Affiliation(s)
- P E R Spronk
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | - K M de Ligt
- Department of Research, Comprehensive Cancer Centre the Netherlands (IKNL), Utrecht, The Netherlands
| | - A C M van Bommel
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - S Siesling
- Department of Research, Comprehensive Cancer Centre the Netherlands (IKNL), Utrecht, The Netherlands; Department of Health Technology and Services Research, MIRA Institute for Biomedical Science and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - C H Smorenburg
- Department of Medical Oncology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Chronological Age and Risk of Chemotherapy Nonfeasibility: A Real-Life Cohort Study of 153 Stage II or III Colorectal Cancer Patients Given Adjuvant-modified FOLFOX6. Am J Clin Oncol 2017; 41:73-80. [PMID: 26669742 DOI: 10.1097/coc.0000000000000233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To assess nonfeasibility of adjuvant-modified FOLFOX6 chemotherapy in patients with stage II or III colorectal cancer. METHODS Consecutive patients managed between 2009 and 2013 in 2 teaching hospitals in the Paris urban area were included in the CORSAGE (COlorectal canceR, AGe, and chemotherapy fEasability study) cohort study. Nonfeasibility was defined by the frequencies of empirical first-cycle dose reduction (>15%), early discontinuation (<12 cycles), and low relative dose intensity (RDI) (<0.85). Risk factors for chemotherapy nonfeasibility were identified using multivariate logistic regression. RESULTS Among 153 patients, 56.2% were male (median age, 65.6 y; 35.3%≥70 y; 7.3% with performance status [PS]≥2). For 5-fluorouracil (5-FU), 20.9% of patients had first-cycle dose reduction and 28.1% early discontinuation; RDI was 0.91 (25th to 75th percentiles, 0.68 to 0.99). Factors independently associated with first-cycle 5-FU dose reduction were aged 65 to 69 years versus those younger than 65 years (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.5-19.9) but not age 70 years and older, PS≥2 (aOR, 6.02; 95% CI, 1.15-31.4), higher Charlson Comorbidity Index (aOR1-point increase, 1.4; 95% CI, 1.05-1.82), or larger number of medications (aOR 1-medication increase, 1.19; 95% CI, 1.00-1.42). Oxaliplatin dose reduction occurred in 52.3% of patients and early discontinuation in 62.7%; the latter was more common in the 70 years and older group (92.6% vs. 74.6% in the <65-y group; P=0.01); RDI was 0.7 (95% CI, 0.55-0.88). CONCLUSIONS In the real-world setting, compared with their younger and older counterparts, patients aged 65 to 69 years given modified FOLFOX6 for stage II or III colorectal cancer had higher frequencies of 5-FU nonfeasibility defined based on first-cycle dose reduction, early discontinuation, and RDI; and these differences were independent from PS, comorbidities, and number of medications.
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Tominaga T, Nonaka T, Sumida Y, Hidaka S, Sawai T, Nagayasu T. Effectiveness of adjuvant chemotherapy for elderly patients with lymph node-positive colorectal cancer. World J Surg Oncol 2016; 14:197. [PMID: 27465031 PMCID: PMC4964014 DOI: 10.1186/s12957-016-0959-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/22/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Several guidelines state that postoperative adjuvant chemotherapy (AC) confers survival benefits to patients with lymph node-positive colorectal cancer. However, older patients are usually not administered AC due to the higher risk of side effects. The aim of this study was to evaluate the benefit of AC for elderly patients (EP) and examine its tolerability. METHODS Data from 204 patients with lymph node-positive colon cancer were retrospectively analyzed. Patients were subdivided into two groups: EP, >75 years old (n = 53) and young patients (YP), <75 years old (n = 151). Clinicopathological features, type of chemotherapy, and outcomes were compared between groups. RESULTS Frequency of comorbidities and performance status were significantly higher in EP (p < 0.01 each), a greater proportion of YP (76 %) than EP received AC (40 %, p < 0.01), and YP received combination therapy more frequently than EP (p < 0.01). In terms of side effects, few EP showed severe side effects. Both YP and EP gained survival benefits from AC (p = 0.07 and p < 0.01, respectively). CONCLUSIONS AC should not be withheld from eligible EP purely because of age.
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Affiliation(s)
- Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Yorihisa Sumida
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Shigekazu Hidaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Terumitsu Sawai
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
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Ko JJ, Kennecke HF, Lim HJ, Renouf DJ, Gill S, Woods R, Speers C, Cheung WY. Reasons for Underuse of Adjuvant Chemotherapy in Elderly Patients With Stage III Colon Cancer. Clin Colorectal Cancer 2015; 15:179-85. [PMID: 26520019 DOI: 10.1016/j.clcc.2015.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Undertreatment has been frequently reported in the elderly cancer patient population. For this reason, we aimed to characterize adjuvant chemotherapy (AC) use among elderly patients (EPs) with stage III colon cancer (CC) and to identify potential reasons for undertreatment. PATIENTS AND METHODS Patients diagnosed with stage III CC between 2008 and 2010 were included in this review. Multivariate Cox regression models were constructed to evaluate the associations between AC and cancer-specific, disease-free, and overall survival and to determine whether these were modified by age. RESULTS We identified 810 patients: 423 (52%) men, 423 (52%) young patients (YPs), and 603 (74%) received AC. Compared with YPs, EPs were less likely to receive AC (57% vs. 91%; P < .01), particularly 5-fluorouracil and oxaliplatin (FOLFOX) (32% vs. 74%, P < .01). Frequent reasons for nontreatment included age, comorbidities, and perceived minimal benefit from AC. When AC was given, EPs had similar rates of treatment discontinuations (34% vs. 26%; P > .05) and dose reductions (63% vs. 61%; P > .05) as YPs. Reasons for treatment interruptions included side effects, progressive disease, and patient choice. Receipt of either FOLFOX or capecitabine was correlated with improved cancer-specific survival, disease-free survival, and overall survival compared with surgery alone; this effect was not modified by age. CONCLUSION Elderly patients with stage III CC frequently received either no AC or capecitabine monotherapy because of advanced age and comorbidities. The effect of AC on survival was similar across age groups, with comparable side effects and rates of treatment modifications. AC should not be withheld because of advanced age alone.
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Affiliation(s)
- Jenny J Ko
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Howard J Lim
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Daniel J Renouf
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Sharlene Gill
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Ryan Woods
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
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