Patient and physician decision styles and breast cancer chemotherapy use in older women: Cancer and Leukemia Group B protocol 369901

The landscape of use of NCCN-guideline chemotherapy regimens in stage I-IIIA breast cancer in an integrated healthcare delivery system

PURPOSE

The National Comprehensive Cancer Network (NCCN) guidelines recommend a variety of drug combinations with specific administration schedules for the treatment of early-stage breast cancer, allowing physicians to deliver treatments recognizing individual patient complexities, including comorbidities, and patient-physician preference. While use of guideline regimens has shifted over time, there is little data to describe changes in how treatment for early-stage breast cancer has evolved over time.

METHODS

In a cohort of 34,109 women treated for stage I-IIIA breast cancer between 2006-2019 at Kaiser Permanente Northern California and Kaiser Permanente Washington, we present the changes in chemotherapy regimens over time, and explore use of NCCN-guideline regimens (GR), guideline regimens used when said regimens were not included in guidelines, referred to as time-discordant regimens (TDR), and non-guideline regimens (NGR). Results are presented by drug combination and over time.

RESULTS

Among 12,506 women receiving chemotherapy, 77.4% (n = 9681) received GRs, 9.1% (n = 1140) received TDRs, and 13.5% (n = 1685) received NGRs. In 2006, AC-T (cyclophosphamide-doxorubicin, paclitaxel) was the most common regimen, with TC (cyclophosphamide-docetaxel) becoming the most prevalent by 2019. NGRs were more common in cyclophosphamide-methotrexate-5-fluorouracil (CMF); cyclophosphamide-doxorubicin-paclitaxel-trastuzumab (ACTH); and paclitaxel-trastuzumab (TH). The use of GR has increased over time (p-trend < 0.001), while use of NGR (both in terms of administration schedule and drug combination) and TDR have decreased, although patterns vary by drug combination.

CONCLUSION

Chemotherapy delivery has changed markedly over time, with a move toward more use of GR. These data are important for understanding the landscape of chemotherapy delivery in community healthcare settings.

Provider responses to the expansion of public subsidies in healthcare: The case of oral chemotherapy treatment in Australia

We examine provider responses to the expansion of public subsidies in 2015 for innovative oral chemotherapy treatment, in a health system where providers were free to determine their own prices. The new treatment was known to have similar efficacy to its traditional intravenous alternative and was preferred by patients for its at-home administration. However, from a policymaker's perspective, the potential for misalignment between patient and provider preferences was significant given the shift to full reimbursement for the oral chemotherapy medication but no change in fee-for-service payments for associated chemotherapy services. Under this scenario, a shift away from traditional intravenous chemotherapy may entail reduced activity and revenues associated with infusions for providers, and we hypothesise that it may result in unintended policy consequences such as reduced take-up of the new therapy or higher prices. We implement a difference-in-difference model using national administrative data on services provided, and chemotherapy medications prescribed, by providers to 1850 patients in New South Wales, Australia. Our estimates indicate that the subsidies expanded access to oral chemotherapy for newly eligible patients by 15 percentage points. However, prices charged by providers for an episode of care rose by 23 percent, driven mostly by increases in service volumes. The results illustrate the importance of understanding differential provider responses to policy changes in financial incentives.

Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study

BACKGROUND

Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes.

OBJECTIVE

To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings.

PARTICIPANTS

Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data.

MAIN MEASURES

Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome.

KEY RESULTS

Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2.

CONCLUSIONS

Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.

Chemotherapy refusal and subsequent survival in healthy older women with high genomic risk estrogen receptor-positive breast cancer

BACKGROUND

Patients with estrogen receptor (ER)-positive, HER2-negative breast cancer (BC), and high-risk 21-gene recurrence score (RS) results benefit from chemotherapy. We evaluated chemotherapy refusal and survival in healthy older women with high-RS, ER-positive BC.

METHODS

Retrospective review of the National Cancer Database (2010-2017) identified women ≥ 65 years of age, with ER-positive, HER2-negative, high-RS (≥ 26) BC. Patients with Charlson Comorbidity Index ≥ 1, stage III/IV disease, or incomplete data were excluded. Women were compared by chemotherapy receipt or refusal using the Cochrane-Armitage test, multivariable logistical regression modeling, the Kaplan-Meier method, and Cox's proportional hazards modeling.

RESULTS

6827 women met study criteria: 5449 (80%) received chemotherapy and 1378 (20%) refused. Compared to women who received chemotherapy, women who refused were older (71 vs 69 years), were diagnosed more recently (2014-2017, 67% vs 61%), and received radiation less frequently (67% vs 71%) (p ≤ 0.05). Refusal was associated with decreased 5-year OS for women 65-74 (92% vs 95%) and 75-79 (85% vs 92%) (p ≤ 0.05), but not for women ≥ 80 years old (84% vs 91%; p = 0.07). On multivariable analysis, hazard of death increased with refusal overall (HR 1.12, 95% CI 1.04-1.2); but, when stratified by age, was not increased for women ≥ 80 years (HR 1.10, 95% CI 0.80-1.51).

CONCLUSIONS

Among healthy women with high-RS, ER-positive BC, chemotherapy refusal was associated with decreased OS for women ages 65-79, but did not impact the OS of women ≥ 80 years old. Genomic testing may have limited utility in this population, warranting prudent shared decision-making and further study.

Effects and Working Mechanisms of a Multilevel Implementation Program for Applying Shared Decision-Making while Discussing Systemic Treatment in Breast Cancer

Background: Enhancing the application of shared decision-making (SDM) is critical for integrating patient preferences in breast cancer treatment choices. We investigated the effect of an adapted multilevel SDM implementation program in breast cancer care. Methods: Breast cancer patients qualifying for (neo)adjuvant systemic treatment were included in a multicenter before−after study. Consultations were audio recorded between June 2018 and July 2019 and analyzed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to score SDM application by clinicians. The Shared Decision-Making Questionnaire (SDM-Q-9) was used to rate patients’ perceived SDM level. Consultation duration, decision types, number of options discussed and consultations per patient were monitored. Regression analysis was used to investigate the correlated variables and program components. Results: Mean OPTION-5 scores increased from 33.9 (n = 63) before implementation to 54.3 (n = 49) after implementation (p < 0.001). The SDM-Q-9 scores did not change: 91.1 (n = 51) at baseline versus 88.9 (n = 23) after implementation (p = 0.81). Without increasing consultation time, clinicians discussed more options after implementation. The regression analysis showed that exposure to the implementation program, redistribution of tasks and discussing feedback from consultations was associated with a higher level of SDM. Conclusion: The multilevel program helped clinicians achieve clinically relevant improvement in SDM, especially when it is tailored to (individuals in) teams and includes (e-)training, discussing feedback on consultations and redistribution of tasks.

Decision-making styles of patients and general population in health care: A scoping review

OBJECTIVE

Decision-making styles form the backbone of effective decision-making and show promise as an important construct that warrants further attention. We investigated what is known about decision-making styles among patients and the general population in a health care setting.

METHODS

We used Arksey and O'Malley's framework and searched PubMed and CINAHL databases using relevant combinations of keywords and subject headings. Articles were limited to those published in English up to February 2020.

RESULTS

Sixteen articles met the inclusion criteria. We found that decision-making styles were described as role preferences or personality, psychological, and cognitive factors that influence decision-making. In the identified studies, the evidence was scarce regarding decision-making styles as the foundation for effective decision-making. Moreover, most studies were vague in the description of decision-making styles, offered little explanation of the concept, and varied substantially in the terminology, numbers, and types of decision-making styles and measurement methods.

CONCLUSIONS

Decision-making styles, as a dynamic process, have received little attention in health care and are rarely addressed in health communication research or investigations of decision-making support. Other frameworks that are not directly related to decision-making styles were used in most analyzed studies.

PRACTICE IMPLICATIONS

Decision-making styles in health care should be reinterpreted as a dynamic process that can be developed or changed.

Place-Based Drivers of Mortality: Evidence from Migration

We estimate the effect of current location on elderly mortality by analyzing outcomes of movers in the Medicare population. We control for movers' origin locations as well as a rich vector of pre-move health measures. We also develop a novel strategy to adjust for remaining unobservables, using the correlation of residual mortality with movers' origins to gauge the importance of omitted variables. We estimate substantial effects of current location. Moving from a 10th to a 90th percentile location would increase life expectancy at age 65 by 1.1 years, and equalizing location effects would reduce cross-sectional variation in life expectancy by 15 percent. Places with favorable life expectancy effects tend to have higher quality and quantity of health care, less extreme climates, lower crime rates, and higher socioeconomic status.

Older adult participation in cancer clinical trials: A systematic review of barriers and interventions

Cancer is a disease of aging and, as the world's population ages, the number of older persons with cancer is increasing and will make up a growing share of the oncology population in virtually every country. Despite this, older patients remain vastly underrepresented in research that sets the standards for cancer treatments. Consequently, most of what we know about cancer therapeutics is based on clinical trials conducted in younger, healthier patients, and effective strategies to improve clinical trial participation of older adults with cancer remain sparse. For this systematic review, the authors evaluated published studies regarding barriers to participation and interventions to improve participation of older adults in cancer trials. The quality of the available evidence was low and, despite a literature describing multifaceted barriers, only one intervention study aimed to increase enrollment of older adults in trials. The findings starkly amplify the paucity of evidence-based, effective strategies to improve participation of this underrepresented population in cancer trials. Within these limitations, the authors provide their opinion on how the current cancer research infrastructure must be modified to accommodate the needs of older patients. Several underused solutions are offered to expand clinical trials to include older adults with cancer. However, as currently constructed, these recommendations alone will not solve the evidence gap in geriatric oncology, and efforts are needed to meet older and frail adults where they are by expanding clinical trials designed specifically for this population and leveraging real-world data.

Outcome of patients with breast cancer in the oldest old (≥80 years)

PURPOSE

In the present study, we present a large institutional study to determine the influence of age≥ 80 years on breast cancer presentation and prognosis.

METHODS

The study is a retrospective analysis of our prospectively maintained breast cancer database study using data from of women managed from January 2007 through December 2013. Clinicopathologic characteristics were correlated with outcomes according to age (<80 years and ≥ 80 years).

RESULTS

During the study period, 2083 women with invasive breast cancer were included of which 160 women aged ≥ 80 years (7.7 %). Overall survival was lower in the oldest old than in younger counterparts (p < 0.0001) as was distant metastasis free survival (p = 0.004). Differences in management included more radical surgeries and less chemotherapy and radiotherapy in case of age≥ 80 years. By multivariate analysis, age ≥ 80 years was an independent predictive factor of poor overall survival.

CONCLUSION

In the present study, age ≥ 80 years was an independent predictive factor of poor overall survival.

Effects of a reimbursement change and travel times on the delivery of private and public radiology services in Norway: a register-based longitudinal study of Norwegian claims data

BACKGROUND

The variation in the impact of the 2008 reimbursement change for Norwegian radiology providers, depending on the travel times to private and public providers in different municipalities, was examined. The activity-based fund allocation for radiology providers was reduced from approximately 50% to 40%, which was compensated by an increased basic grant. The hypothesis was that the Norwegian population would be affected by the reimbursement change unevenly depending on their distances to different types of the providers.

METHODS

The study of the effect of the reimbursement change and travel time difference between private and public radiology providers in Norway (Time_difference) on the number of the services was performed using fixed-effects regressions applied to panel data at the municipality level with monthly observations for the period 2007-2010.

RESULTS

After the reimbursement change, the number of private services decreased more than the number of public services. Private services declined after 2008, but the absolute value of the effect was smaller as the Time_difference became greater. The number of public services increased as the Time_difference grew. The total number of services decreased until the Time_difference was equal to 40 min and increased for time differences greater than 40 min.

CONCLUSIONS

The messages for policymakers are as follows. Populations that only had private providers nearby were more affected by the reimbursement change in terms of a reduced number of services. The reimbursement change contributed to the reallocation of patients from private to public providers. The difference between the centralities of municipalities in their consumption patterns was reduced and the difference between different Regional Health Authorities was increased due to the reimbursement change.

Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spendingf

There is considerable controversy about the causes of regional variations in health care expenditures. Using vignettes from patient and physician surveys linked to fee-for-service Medicare expenditures, this study asks whether patient demand-side factors or physician supply-side factors explain these variations. The results indicate that patient demand is relatively unimportant in explaining variations. Physician organizational factors matter, but the most important factor is physician beliefs about treatment. In Medicare, we estimate that 35 percent of spending for end-of-life care and 12 percent of spending for heart attack patients (and for all enrollees) is associated with physician beliefs unsupported by clinical evidence. (JEL D83, H75, I11, I18).

Cognitive function and discontinuation of adjuvant hormonal therapy in older breast cancer survivors: CALGB 369901 (Alliance)

PURPOSE

To investigate the effects of cognitive function on discontinuation of hormonal therapy in breast cancer survivors ages 65+ ("older").

METHODS

Older breast cancer survivors with invasive, non-metastatic disease, and no reported cognitive difficulties were recruited from 78 Alliance sites between 2004 and 2011. Eligible survivors (n = 1280) completed baseline interviews; follow-up was conducted annually for up to 7 years. Survivors with estrogen-receptor-positive (ER+) cancers who initiated hormonal therapy (n = 990) were included. Self-reported cognitive function was measured using the EORTC-QLQ30 scale; a difference of eight points on the 0-100 scale was considered clinically significant. Based on varying rates of discontinuation over time, discontinuation was evaluated separately for three time periods: early (<1 year); midpoint (1-3 years); and late discontinuation (>3-5 years). Cox models for each time period were used to evaluate the effects of cognition immediately preceding discontinuation, controlling for age, chemotherapy, and other covariates.

RESULTS

Survivors were 65-91 years old (mean 72.6 years), and 79% had stages 1 or 2A disease. Overall, 43% discontinued hormonal therapy before 5 years. Survivors who reported lower cognitive function in the period before discontinuation had greater hazards of discontinuing therapy at the treatment midpoint (HR 1.22 per 8-point difference, CI 1.09-1.40, p < 0.001), considering covariates, but cognition was not related to discontinuation in the other periods.

CONCLUSIONS

Self-reported cognitive problems were a significant risk factor for discontinuation of hormonal therapy 1-3 years post-initiation. Additional research is needed on the temporality of cognitive effects and hormonal therapy to support survivorship care needs of older survivors.

Frailty and long-term mortality of older breast cancer patients: CALGB 369901 (Alliance)

PURPOSE

Breast cancer patients aged 65+ ("older") vary in frailty status. We tested whether a deficits accumulation frailty index predicted long-term mortality.

METHODS

Older patients (n = 1280) with non-metastatic, invasive breast cancer were recruited from 78 Alliance sites from 2004 to 2011, with follow-up to 2015. Frailty categories (robust, pre-frail, and frail) were based on 35 baseline illness and function items. Cox proportional hazards and competing risk models were used to calculate all-cause and breast cancer-specific mortality for up to 7 years, respectively. Potential covariates included demographic, psychosocial, and clinical factors, diagnosis year, and care setting.

RESULTS

Patients were 65-91 years old. Most (76.6%) were robust; 18.3% were pre-frail, and 5.1% frail. Robust patients tended to receive more chemotherapy ± hormonal therapy (vs. hormonal) than pre-frail or frail patients (45% vs. 37 and 36%, p = 0.06), and had the highest adherence to hormonal therapy. The adjusted hazard ratios for all-cause mortality (n = 209 deaths) were 1.7 (95% CI 1.2-2.4) and 2.4 (95% CI 1.5-4.0) for pre-frail and frail versus robust women, respectively, with an absolute mortality difference of 23.5%. The adjusted hazard of breast cancer death (n-99) was 3.1 (95% CI 1.6-5.8) times higher for frail versus robust patients (absolute difference of 14%). Treatment differences did not account for the relationships between frailty and mortality.

CONCLUSIONS

Most older breast cancer patients are robust and could consider chemotherapy where otherwise indicated. Patients who are frail or pre-frail have elevated long-term all-cause and breast cancer mortality. Frailty indices could be useful for treatment decision-making and care planning with older patients.

Using ePrognosis to estimate 2-year all-cause mortality in older women with breast cancer: Cancer and Leukemia Group B (CALGB) 49907 and 369901 (Alliance A151503)

PURPOSE

Tools to estimate survival, such as ePrognosis ( http://eprognosis.ucsf.edu/carey2.php ), were developed for general, not cancer, populations. In older patients with breast cancer, accurate overall survival estimates would facilitate discussions about adjuvant therapies.

METHODS

Secondary analyses were performed of data from two parallel breast cancer studies (CALGB/Alliance 49907/NCT000224102 and CALGB/Alliance 369901/NCT00068328). We included patients (n = 971) who were age 70 years and older with complete baseline quality of life data (194 from 49907; 777 from 369901). Estimated versus observed all-cause two-year mortality rates were compared. ePrognosis score was calculated based on age, sex, and daily function (derived from EORTC QLQ-C30). ePrognosis scores range from 0 to 10, with higher scores indicating worse prognosis based on mortality of community-dwelling elders and were categorized into three groups (0-2, 3-6, 7-10). Observed mortality rates were estimated using Kaplan-Meier methods.

RESULTS

Patient mean age was 75.8 years (range 70-91) and 73% had stage I-IIA disease. Most patients were classified by ePrognosis as good prognosis (n = 562, 58% 0-2) and few (n = 18, 2% 7-10) poor prognosis. Two-year observed mortality rates were significantly lower than ePrognosis estimates for patients scoring 0-2 (2% vs 5%, p = 0.001) and 3-6 (8% vs 12%, p = 0.01). The same trend was seen with scores of 7-10 (23% vs 36%, p = 0.25).

CONCLUSIONS

ePrognosis tool only modestly overestimates mortality rate in older breast cancer patients enrolled in two cooperative group studies. This tool, which estimates non-cancer mortality risk based on readily available clinical information may inform adjuvant therapy decisions but should be validated in non-clinical trial populations.

Physician Preferences for Aggressive Treatment at the End of Life and Area-Level Health Care Spending: The Johns Hopkins Precursors Study

Objective: To determine whether physician preferences for end-of-life care were associated with variation in health care spending. Method: We studied 737 physicians who completed the life-sustaining treatment questionnaire in 1999 and were linked to end-of-life care data for the years 1999 to 2009 from Medicare-eligible beneficiaries from the Dartmouth Atlas of Health Care (in hospital-related regions [HRRs]). Using latent class analysis to group physician preferences for end-of-life treatment into most, intermediate, and least aggressive categories, we examined how physician preferences were associated with health care spending over a 7-year period. Results: When all HRRs in the nation were arrayed in quartiles by spending, the prevalence of study physicians who preferred aggressive end-of-life care was greater in the highest spending HRRs. The mean area-level intensive care unit charges per patient were estimated to be US$1,595 higher in the last 6 months of life and US$657 higher during the hospitalization in which death occurred for physicians who preferred the most aggressive treatment at the end of life, when compared with average spending. Conclusions: Physician preference for aggressive end-of-life care was correlated with area-level spending in the last 6 months of life. Policy measures intended to minimize geographic variation in health care spending should incorporate physician preferences and style.

Long-term trajectories of self-reported cognitive function in a cohort of older survivors of breast cancer: CALGB 369901 (Alliance)

BACKGROUND

The number of survivors of breast cancer aged ≥65 years (“older”) is growing, but to the authors' knowledge, little is known regarding the cognitive outcomes of these individuals.

METHODS

A cohort of cognitively intact older survivors with nonmetastatic, invasive breast cancer was recruited from 78 sites from 2004 through 2011; approximately 83.7% of the survivors (1280 survivors) completed baseline assessments. Follow‐up data were collected at 6 months and annually for up to 7 years (median, 4.1 years). Cognitive function was self‐reported using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ‐C30); scores ranged from 0 to 100, with a higher score indicating better function. Group‐based trajectory modeling determined trajectories; women were assigned to a trajectory group based on the highest predicted probability of membership. Multinomial logistic regression evaluated the association between receipt of chemotherapy (with or without hormonal treatment) and trajectory group.

RESULTS

Survivors were aged 65 to 91 years; approximately 41% received chemotherapy. There were 3 cognitive trajectories: “maintained high” (42.3% of survivors); “phase shift” (50.1% of survivors), with scores slightly below but parallel to maintained high; and “accelerated decline” (7.6% of survivors), with the lowest baseline scores and greatest decline (from 71.7 [standard deviation, 19.8] to 58.3 [standard deviation, 21.9]). The adjusted odds of being in the accelerated decline group (vs the maintained high group) were 2.1 times higher (95% confidence interval, 1.3‐3.5) for survivors who received chemotherapy (with or without hormonal therapy) versus those treated with hormonal therapy alone. Greater comorbidity and frailty also were found to be associated with accelerated decline.

CONCLUSIONS

Trajectory group analysis demonstrated that the majority of older survivors maintained good long‐term self‐reported cognitive function, and that only a small subset who were exposed to chemotherapy manifested accelerated cognitive decline. Future research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline. Cancer 2016;122:3555–3563. © 2016 American Cancer Society

Among older survivors of breast cancer who were followed for up to 7 years, approximately 42% reported maintaining high cognitive function, but receipt of chemotherapy (with or without hormonal therapy) appeared to double the odds of being in the group that reported accelerated cognitive decline (vs maintaining high function), compared with receiving hormonal treatment alone. Further research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline.

Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival

AIM: To examine the influence of gynecologic oncologists (GO) in the United States on surgical/chemotherapeutic standard of care (SOC), and how this translates into improved survival among women with ovarian cancer (OC).

METHODS: Surveillance, Epidemiology, and End Result (SEER)-Medicare data were used to identify 11688 OC patients (1992-2006). Only Medicare recipients with an initial surgical procedure code (n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOC and proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival.

RESULTS: About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC (P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22 (95%CI: 1.12-1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs (for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC.

CONCLUSION: A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.

Trends in breast cancer in the elderly in Denmark, 1980-2012

BACKGROUND

Breast cancer is the most frequent malignancy among women worldwide and the second most common cause of cancer-related death in developed countries. The aim of the present analysis is to describe trends in incidence, mortality, prevalence, and relative survival in Denmark from 1980 to 2012 focusing on age, comparing persons aged 70 years or more with those aged less than 70 years.

MATERIAL AND METHODS

Cancer of the breast was defined as ICD-10 code C50. Data derived from the NORDCAN database with comparable data on cancer incidence, mortality, prevalence and relative survival in the Nordic countries, where the Danish data were delivered from the Danish Cancer Registry and the Danish Cause of Death Registry with follow-up for death or emigration until the end of 2013.

RESULTS

The proportion of patients diagnosed with breast cancer over the age of 70 years increased with time to 29% of women and 44% of men in 2012. Incidence rates increased with time and peaked around 2010 in all age groups except for those aged 90 years or more. Mortality rates were clearly separated by age with increasing mortality rates by increasing age group for both women and men. Relative survival increased over time in all age groups, but patients aged 70 years or more had a poorer relative survival than those aged less than 70 years. In 2012, 58 521 persons (all ages) were alive in Denmark after a diagnosis of breast cancer.

CONCLUSION

Poorer survival of Danish breast cancer patients over the age of 70 years is likely to be due to inferior treatment and non-adherence to treatment guidelines. There is a need for clinical trials focusing on patients over the age of 70 years.

A patient perspective on shared decision making in stage I non-small cell lung cancer: a mixed methods study

Background

Surgery and stereotactic ablative radiotherapy (SABR) are both curative treatment options for patients with a stage I non-small cell lung cancer (NSCLC). Consequently, there is growing interest in studying the role of patients in treatment decision making. We studied how patients with stage I NSCLC perceived shared decision making (SDM) in general, and how they viewed different aspects of SDM.

Methods

A sequential mixed methods design was used, consisting of qualitative interviews (N = 11), as well as a survey study (N = 76) focusing on different SDM-related aspects. Participants were interviewed to understand their own experience with treatment decision making. In the survey study, patients rated the importance of 20 aspects of shared decision making that were identified during interviews. Descriptive analysis and explorative factor analysis were performed.

Results

We assessed six qualitative themes covering SDM aspects that were determined by patients to be important. The survey identified four SDM-related factors with sufficient internal consistency, namely (1) ‘guidance by clinician’ (α = .741), (2) ‘conduct of clinician’ (α = .774); (3) ‘preparation for treatment decision making’ (α = .864); and (4) ‘active role of patient in treatment decision making’ (α = .782). Of these, clinician guidance was rated as most important by patients (M = 3.61; SD = .44). Only 28.9 % of patients in the survey study reported that both treatment options were discussed with them.

Conclusions

Patients with a stage I NSCLC found clinician guidance to be important when making treatment decisions. Nevertheless, the majority of patients reported not being offered both treatment options, which might have influenced this finding.

Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer

PURPOSE

We assessed the associations between the 21-gene recurrence score assay (RS) receipt, subsequent chemotherapy use, and medical expenditures among patients with early-stage breast cancer.

PATIENTS AND METHODS

Data from the Pennsylvania Cancer Registry were used to assemble a retrospective cohort of women with early-stage breast cancer from 2007 to 2010 who underwent initial surgical treatment. These data were merged with administrative claims from the 12-month periods before and after diagnosis to identify comorbidities, treatments, and expenditures (n = 7,287). Propensity score-weighted regression models were estimated to identify the effects of RS receipt on chemotherapy use and medical spending in the year after diagnosis.

RESULTS

The associations between RS receipt and outcomes varied markedly by patient age. RS use was associated with lower chemotherapy use among women younger than 55 (19.2% lower; 95% CI, 10.6 to 27.9). RS use was associated with higher chemotherapy use among women 75 to 84 years old (5.7% higher; 95% CI, 0.4 to 11.0). RS receipt was associated with lower adjusted 1-year medical spending among women younger than 55 ($15,333 lower; 95% CI, $2,841 to $27,824) and with higher spending among women who were 75 to 84 years old ($3,489 higher; 95% CI, $857 to $6,122).

CONCLUSION

RS receipt was associated with reduced use of adjuvant chemotherapy and lower health care spending among women with breast cancer who were younger than 55. Conversely, among women 75 and older, RS testing was associated with a modest increase in chemotherapy use and slightly higher spending. From a population perspective, the impact of RS testing on breast cancer treatment and health care costs is much greater in younger women.

Implementing and evaluating shared decision making in oncology practice

Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.

Present status of adjuvant chemotherapy for elderly breast cancer patients

Elderly breast cancer patients are underrepresented in clinical trials, leading to a lack of knowledge regarding their tolerance of modern chemotherapy regimens. In addition, physicians are often reluctant to treat older patients with chemotherapy due to potential side effects. This article summarizes the up-to-date literature on chemotherapy in elderly patients with breast cancer, evaluates the impact of the patients' comorbidities and treatment alterations and aims to encourage treating patients adequately according to their disease in combination with the biological age rather than the chronological age alone. Finally, a short overview is given of the recruiting studies in Europe evaluating chemotherapy in elderly patients.

Frailty and adherence to adjuvant hormonal therapy in older women with breast cancer: CALGB protocol 369901

PURPOSE

Most patients with breast cancer age ≥ 65 years (ie, older patients) are eligible for adjuvant hormonal therapy, but use is not universal. We examined the influence of frailty on hormonal therapy noninitiation and discontinuation.

PATIENTS AND METHODS

A prospective cohort of 1,288 older women diagnosed with invasive, nonmetastatic breast cancer recruited from 78 sites from 2004 to 2011 were included (1,062 had estrogen receptor-positive tumors). Interviews were conducted at baseline, 6 months, and annually for up to 7 years to collect sociodemographic, health care, and psychosocial data. Hormonal initiation was defined from records and discontinuation from self-report. Baseline frailty was measured using a previously validated 35-item scale and grouped as prefrail or frail versus robust. Logistic regression and proportional hazards models were used to assess factors associated with noninitiation and discontinuation, respectively.

RESULTS

Most women (76.4%) were robust. Noninitiation of hormonal therapy was low (14%), but in prefrail or frail (v robust) women the odds of noninitiation were 1.63 times as high (95% CI, 1.11 to 2.40; P = .013) after covariate adjustment. Nonwhites (v whites) had higher odds of noninitiation (odds ratio, 1.71; 95% CI, 1.04 to 2.80; P = .033) after covariate adjustment. Among initiators, the 5-year continuation probability was 48.5%. After adjustment, the risk of discontinuation was higher with increasing age (P = .005) and lower for stage ≥ IIB (v stage I) disease (P = .003).

CONCLUSION

Frailty is associated with noninitiation of hormonal therapy, but it does not seem to be a major predictor of early discontinuation in older patients.

Associations among survivorship care plans, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901

PURPOSE

Survivorship care plans (SCP) are recommended for all cancer patients and could be especially useful to survivors 65 years and over ("older"). This study examined receipt of SCPs among older breast cancer survivors and whether SCPs were associated with improved patient-reported outcomes.

METHODS

Three hundred and twenty-eight older women diagnosed with invasive, nonmetastatic breast cancer between 2007-2011 were recruited from 78 cooperative-group sites. Participants completed telephone interviews at baseline and 1-year posttreatment. Regression analyses examined SCP receipt (yes/no) and functioning (EORTC-QLQ-C30), cancer worry, and experiences of survivorship care (care coordination, knowledge).

RESULTS

Only 35% of women received SCPs. For each 1-year increase in age, there was a 5% lower odds of receiving an SCP (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.91-0.98, p = 0.007). Besides age, no other factor predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow-up care (p < 0.05); however, functioning was not significantly different among those with vs. without SCPs.

CONCLUSIONS

Receipt of care plans was limited. SCPs improved understanding of breast cancer follow-up care among older survivors, but did not impact functioning one year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

To impact functioning and salient needs of the growing cohort of older survivors, survivorship care plans likely should be tailored to geriatric-specific issues. To improve functioning, SCP content should expand to include exercise, nutrition, polypharmacy, social support and management of symptom burden from cancer, and other comorbid conditions. To improve follow-up care for cancer survivors, SCPs should delineate shared care roles between oncology and primary care in managing recurrence surveillance, screening, and cancer sequelae.

Intended versus inferred care after PET performed for initial staging in the National Oncologic PET Registry

The National Oncologic PET Registry (NOPR) collected data on intended management before and after PET in cancer patients. We have previously reported that PET was associated with a change in intended management of about one third of patients and was consistent across cancer types. It is uncertain if intended management plans reflect the actual care these patients received. One approach to assess actual care received is using administrative claims to categorize the type and timing of clinical services.

METHODS

NOPR data from 2006 to 2008 were linked to Medicare claims for consenting patients aged 65 y or older undergoing initial-staging PET scanning for bladder, ovarian, pancreatic, small cell lung, or stomach cancers. We determined the 60-d agreement between claims-inferred care and NOPR treatment plans.

RESULTS

Patients (n = 4,661) were assessed, and 30%-52% had metastatic disease. Planned treatments were about two-thirds monotherapy, of which 46% was systemic therapy only, and one-third combinations. Claims paid by 60 d confirmed the NOPR plan of any systemic therapy, radiotherapy, or surgery in 79.3%, 64.7%, and 63.6%, respectively. Single-mode plans were much more often confirmed: systemic therapy in more than 85% of patients with ovarian, pancreatic, and small cell lung cancers and surgery in more than 73% of those with bladder, pancreatic, and stomach cancers. Intended combination treatments had claims for both in only 28% of patients receiving surgery-based combinations and in 55% receiving chemoradiotherapy. About 90% of patients with NOPR-planned systemic therapy had evaluation or management claims from a medical oncologist. An age of less than 75 y was associated more often with confirmation of chemotherapy, less often for radiotherapy but not with confirmation of surgery. Performance status or comorbidity did not explain confirmation rates within action categories, but confirmation rates were higher if the referrer specialized in the planned treatment.

CONCLUSION

Claims confirmations of NOPR intent for initial staging were widely variable but were higher than previously reported for restaging PET, suggesting that measuring change in intended management is a reasonable method for assessing the impact diagnostic tests have on actual care.

Narrowing racial gaps in breast cancer chemotherapy initiation: the role of the patient-provider relationship

Chemotherapy improves breast cancer survival but is underused more often in black than in white women. We examined associations between patient-physician relationships and chemotherapy initiation and timeliness of initiation among black and white patients. Women with primary invasive, non-metastatic breast cancer were recruited via hospitals (in Washington, DC and Detroit) and community outreach between July 2006 and April 2011. Data were collected via telephone interviews and medical records. Logistic regression models evaluated associations between chemotherapy initiation and independent variables. Since there were race interactions, analyses were race-stratified. Factors associated with time from surgery to chemotherapy initiation and delay of ≥90 days were evaluated with linear and logistic regressions, respectively. Among eligible women, 82.8 % were interviewed and 359 (90.9 %) of those had complete data. The odds of initiating chemotherapy were 3.26 times (95 % CI: 1.51, 7.06) higher among black women reporting greater communication with physicians (vs. lesser), after considering covariates. In contrast, the odds of starting chemotherapy were lower for white women reporting greater communication (vs. lesser) (adjusted OR 0.22, 95 % CI: 0.07, 0.73). The opposing direction of associations was also seen among the sub-set of black and white women with definitive clinical indications for chemotherapy. Among those initiating treatment, black women had longer mean time to the start of chemotherapy than whites (71.8 vs. 55.0 days, p = 0.005), but race was not significant after considering trust in oncologists, where initiation time decreased as trust increased, controlling for covariates. Black women were also more likely to delay ≥90 days than whites (27 vs. 8.3 %; p = 0.024), but this was not significant after considering religiosity. The patient-physician dyad and sociocultural factors may represent leverage points to improve chemotherapy patterns in black women.

Gender differences in colon cancer treatment

Abstract Background: Despite women suffering a disproportionate burden of colon cancer mortality, few studies have examined gender differences in evidence-based treatment, especially in poorer states like Alabama.

OBJECTIVE

To describe colon cancer treatment in older patients diagnosed in Alabama by gender.

METHODS

Colon cancer patients 65 years and older diagnosed in 2000-2002 were identified from the Alabama Statewide Cancer Registry (N=1785). Treatment was identified from Medicare claims for 1999-2003. Outcomes were (1) receipt of surgery and adjuvant 5-fluorouracil chemotherapy (5FU) and (2) 5FU treatment duration (0-4, 5-7, and >7 months). Generalized Estimating Equation (GEE) models were used to determine significant gender differences, adjusting for clustering at the reporting hospital level, and controlling for race, age, stage, comorbid conditions, census tract-level socioeconomic variables, and adverse chemotherapy effects (when analyzing 5FU duration).

RESULTS

Overall, 93.9% of the patients received surgery. Of stage II-III patients undergoing surgery, 60.4% stage III and 25.6% stage II patients received 5FU. Compared with men, women were more likely to have surgery (95.5% vs. 92.2%, p=0.003), less likely to have 5FU (38.6% vs. 45.2%, p=0.02), and more likely to have 0-4 months of 5FU (32.9% vs. 24.9%, p=0.05). Gender differences were significant for having chemotherapy (adjusted odds ratio [aOR] 0.78, confidence interval [CI] 0.61-1.00, p=0.049), but not for having 0-4 months of 5FU when adjusting for adverse effects (aOR 1.36, CI 0.95-1.94, p=0.09).

CONCLUSIONS

In Alabama, some gender differences in stage-specific colon cancer treatment are worth further scrutiny.