The OBR Blog

October 23, 2014 - 10:10 am Posted in Featured comments0 Comments

Palliative care is finally getting its due, with the kickoff of the Inaugural Palliative Care in Oncology Symposium in Boston, MA, Friday, October 24, 2014. The Symposium is jointly sponsored by four medical societies: American Society of Clinical Oncology (ASCO), American Academy of Hospice and Palliative Medicine (AAHPM), American Society for Radiation Oncology (ASTRO), and the Multinational Association of Supportive Care in Cancer (MASCC).

Themes of the Palliative Care in Oncology Symposium segue from presentations at last week’s ASCO Quality Care Symposium. At that meeting, the focus was on palliative care—an important component of quality care, especially at end of life. Billions of dollars a year are wasted on unnecessary direct care, much of it on end of life care (in fact a 2012 IOM report states that it reaches $210 billion each year).  The field is moving toward greater acceptance and use of palliative care when appropriate.

The pre-symposium press cast for the Palliative Care Symposium featured four presentations that addressed strategies to improve palliative care and the treatment-related financial burdens of cancer care for patients (referred to by quality care experts as “financial toxicity”).

Addressing Patients’ Financial Burdens (Abstracts 238 and 161)

In an analysis of nearly 1600 cancer survivors, a sizeable proportion of cancer patients reported financial and work-related burdens: about half were under age 65; 96% reported some kind of insurance; 27% reported at least one financial difficulty (defined as borrowing money, debt, bankruptcy, worry, and financial sacrifices), and 37% reported having to make at least one work modification (defined as early retirement, changing jobs, turning a promotion down, unpaid or extended leave) due to a cancer diagnosis.

People younger than age 65 reported 130% more financial difficulties than older survivors; the uninsured had 67% more financial difficulties than the insured; and minority groups reported 42% more financial difficulties than whites. The 14% of patients currently in active treatment made 120% more work modifications than those less than 5 years post-treatment; non-white minorities made 57% more work modifications than whites.

Lead author Robin Whitney, RN, BSN, a cancer survivor and PhD student at the University of California, Davis, Betty Irene Moore School of Nursing, said: “Many cancer survivors, particularly those who are younger and from underserved populations, experience financial or work-related hardship –even when insured and years out from treatment.” She and her co-authors say the findings of this study are generalizable to the U.S. population and reveal the need for screening and support for financial and work challenges across the survivorship trajectory.

“We now have more than 12 million cancer survivors,” said press cast moderator Jyoti Patel, MD, representing ASCO, “We need to address their financial hardships. As we deal with the consequences of cancer treatment and therapy, we need to find creative ways to address these burdens.”

Cancer Patients Make Lifestyle Adjustments

A related nationwide survey showed that due to treatment-related financial burdens, many insured cancer patients either make adjustments in lifestyle or make a compromise with their medical care. The study included 174 patients currently undergoing treatment for solid tumors—all of them insured and requesting financial assistance through a national copay assistance program.

Overall, 89% reported at least one lifestyle-altering strategy while 39% reported at least one medical care-altering strategy. Most common medical care-altering strategies were not filling a prescription (28%) and taking less medication than prescribed (23%). Lifestyle-altering coping strategies included spending less money on leisure activities (78%), spending less on food and clothing (57%), borrowing money (54%), and spending savings (50%).Younger age and lower income people were associated with increased care-altering strategies; while younger age, higher education level, and shorter time on chemotherapy were associated with greater likelihood of adopting lifestyle coping strategies compared with their counterparts.

“We need a better, more open dialog between patients and providers about the financial burdens associated with cancer care costs. People use a range of coping strategies, and we need to engage with patients on their choices and develop screening tools to identify patients who are likely to make potentially harmful decisions about their treatment,” said lead author Ryan Nipp, MD, an oncology fellow at Dana-Farber Cancer Institute in Boston.

Dr. Patel commented, “As we make strides in understanding the whole patient, it is incumbent upon us to have these discussions about financial burden with them. We need guided efforts to help support these patients, especially those at risk.”

“Co-Rounding” at Duke (Abstract 3)

According to a retrospective cohort analysis of a pioneering approach of “co-rounding” at Duke University Medical Center, daily collaboration between medical oncologists and palliative care specialists improved health system-related and patient-related outcomes. “Co-rounding” teams included 1 medical oncologist and 1 palliative care specialist as attending physicians, as well as ancillary healthcare providers. The teams met each day to discuss individual patients.

This first evaluation of “co-rounding” at Duke took place after one year of the new partnership which functioned in the hospital’s inpatient solid tumor oncology unit. Comparison between 731 patients admitted pre-intervention and 783 admitted in the first year of the intervention showed that “co-rounding” was associated with a significant decrease in length of hospital stay (4.17 days versus 4.51 days, respectively, P=.02); 15% reduction in the risk of 7-day readmission (P<.0001), and a 23% risk reduction for 30-day readmission (P=.048). ICU transfers were decreased by 15% from pre- to post-intervention, and hospice referrals were increased by 17% after “co-rounding” was instituted. Doctors and nurses expressed satisfaction with the new approach.

“Leveraging the skill sets of both palliative care physicians and medical oncologists has allowed us to better manage symptoms, shorten hospital stays, and prevent readmissions. We’ve also been able to dispel any misconceptions that individuals may have had about the role of palliative care, and we’ve shown that nursing and physician impressions of palliative care, as a whole, are very favorable,” stated lead author Richard Riedel, MD, Duke University Medical Center, Durham, NC.

“This study shows that integrating palliative care into oncology defines good oncologic care. We see that a novel approach called ‘co-rounding’ has achieved impressive results,” Dr. Patel stated.

“Smart Phone” System for Home Hospice (Abstract 85)

Preliminary findings from a randomized study of 319 hospice dyads and 121 nurses (some cared for multiple families) suggest that daily use of “smart technology” with an automated telephone-based remote symptom monitoring and coaching system alleviated patients’ symptoms and caregiver burden during home hospice care in the final weeks of life. The study population was drawn from 12 hospices in four different states. Almost half the patients (n=153) were randomly assigned to the intervention and the other patients (n=166) received usual care, which entailed symptom reporting alone.

“This is the first study to evaluate automated collection of patient-reported symptoms and its effect on family caregiver well-being and on coaching families on ways to improve care for their family member,” said lead study author Kathi Mooney, PhD, RN, Utah College of Nursing and the Huntsman Cancer Institute in Salt Lake City.

“Remote symptom care, working through the caregiver, provides benefits to the dying patient and caregiver,” stated Bob Wong, PhD, a statistician from the same institution who was an author of the study.

The automated, telephone-based symptom monitoring system used computer-based technology; the caregiver entered daily ratings (0-10, with 10 being the most severe) for 11 common symptoms that the patient could have experienced in the past 24 hours, and then got feedback from the system if any of the symptoms were rated 4 or higher. The feedback included tips for the caregiver about how to relieve patient’s symptoms; for example, coaching on such maneuvers as positioning the patient for greater comfort or improved breathing, and how to improve time together. Caregivers also reported their own difficulties during the past 24 hours, such as fatigue, anxiety, difficulty sleeping and negative mood.

Over a 91-day period, patients whose caregivers were assigned to the automated system experienced 44% fewer days of moderate or severe fatigue or anxiety compared with patients in the usual care group. Caregivers in the intervention group had no worsening of vitality (as measured by daily functioning and sleep) over that period, while the usual care caregivers had worsened vitality.

“Caregiving is a 24-hour-a-day, 7-days-a-week job,” Dr. Patel commented. “Most caregivers cannot do it alone. This remote monitoring system proactively supports the caregiver at this difficult time when the patient is near death.”

By Alice Goodman

October 17, 2014 - 11:10 am Posted in Featured comments0 Comments

Introduction

In an effort to provide you with timely market feedback from ESMO 2014, OBR and MDoutlook are pleased to share results from MDoutlook’s OncoPoll™ from the meeting. This report explored presentations in HER2+ Breast Cancer.

OncoPoll™ Methodology

  • Primary research phase involved a global survey to verified and validated medical oncologists and multi-disciplinary physicians with an identified clinical interest in breast cancer utilizing targeting parameters within the proprietary MDoutlook® global cancer treater database
  • Timing: October 2014. Launched three days after close of ESMO 2014 Congress, held in Madrid, Spain September 26th – 30th, 2014
  • Fielding via <10 minute long interactive internet survey utilizing proven effective methodology via the MDoutlook® survey tool
  • Links to discussed abstracts on the ESMO website were provided within the survey
  • Reponses at data collection: 104 on October 13th
    • 37 US respondents
    • 67 EU/Rest of World (RoW) respondents
    • 28 countries represented
  • No financial incentives provided for participation

Attendance at 2014 ESMO Congress

Key Conclusions

  • Nearly a 50/50 split of EU/Rest of world (RoW) respondents* attended the ESMO 2014 Congress
  • US survey respondents were nearly five times less likely to attend ESMO 2014, in comparison to their international counterparts

* Survey Participants = Medical Oncologists with an identified clinical interest in breast cancer

Survey Participants’ Metastatic Breast Cancer Patient Flow: Average Over 40 Breast Cancer Cases Each Quarter

Key Conclusions

  • On average, US oncologists reported seeing more patients in all three subtypes in the last three months, in comparison to their international colleagues
  • US oncologists see nearly 14 HER2+ patients per quarter
    • EU/RoW oncologists see nearly 11 HER2+ patients per quarter
  • Cases of HR+/HER- metastatic breast cancer were more common for both US oncologists (avg. 28/quarter) and EU/RoW oncologists (avg. 26/quarter) than other metastatic breast cancers

Impact of the Phase III Cleopatra Study: EU/RoW Oncologists Expecting to Increase Usage of Trastuzumab+Pertuzumab in the Next Year for HER2+ Metastatic Breast Cancer Patients


Key Conclusions

EU/RoW Clinicians

  • The majority of EU/RoW oncologists (65%) are currently using Trastuzumab combined with chemotherapy alone for their HER2+ metastatic breast cancer (in all lines of therapy). 23% of EU/RoW oncologists are using Trastuzumab+Pertuzumab, and 11% are using Trastuzumab emtansine
  • In the next year, nearly all EU/RoW oncologists expect to completely forego the use of Trastuzumab alone for their metastatic patients (in all lines of therapy)
  • In the next year, 52% of EU/RoW oncologists expect to use Trastuzumab + Pertuzumab. Additionally, 55% of EU/RoW oncologists expect to use Trastuzumab emtansine for their HER2+ metatstatic breast cancer patients (in all lines of therapy)

US clinicians

  • Currently, US oncologists are utilizing several HER2+ targeted therapies, with 49% using Trastuzumab, 49% using Trastuzumab+Pertuzumab, and 38% using Trastuzumab emtansine for their HER2+ metastatic patients (in all lines of therapy)
  • In the next year, a minimal proportion (10%) of US oncologists will be using Trastuzumab alone
  • In the next year, 64% expect to use Trastuzumab emtansine while only 39% of US oncologists expect to use Trastuzumab + Pertuzumab for their HER2+ metastatic patients (in all lines of therapy)

Impact of the Phase III Cleopatra Study: US and EU/RoW Oncologists Expect to Use Trastuzumab+Pertuzumab in the First Line for their HER2+ Metastatic Breast Cancer Patients


Key Conclusion

  • When Trastuzumab+Pertuzumab is used, ~75% of both US and EU/RoW oncologists expect to use it as a first line therapy for their HER2+ metastatic patients

Impact of the CherLOB Study: The Majority of US and EU/RoW Oncologists Believe the Data Presented in the CherLOB Study is Clinically Important


Key Conclusions

  • 75% of US oncologists rated the clinical importance of this study highly (either a four or five)
    • Similarly, 61% of EU/RoW oncologists rated this data to be either a four or five
    • Very few (<5%) oncologists rated this study as not having clinical importance

Impact of the CherLOB Study: US and EU/RoW Oncologists Expect to Increase Testing for the PIK3CA Mutations in HER2+ Breast Cancer Patients


Key Conclusions

  • In the past year, minimal PIK3CA mutation testing by US and EU/RoW oncologists was occurring for HER2+ breast cancer patients (<10%)
  • Due to the correlation between the PIK3CA mutation and pathological complete response (pCR) in patients with HER2+ early breast cancer being treated with neoadjuvant lapatinib and trastuzumab, both US and EU/RoW oncologists expect to increase testing for PIK3CA mutations in both early and metastatic breast cancer patients
    • 31% of early breast cancer patients being treated by US oncologists will be tested for the PIK3CA mutation in the next year
      • This data had less of an effect on EU/RoW oncologists: 16% of early breast cancer patients will be tested
  • Over 40% of metastatic breast cancer patients being treated by US oncologists will be tested
    • Nearly 1 in 5 of metastatic breast cancer patients being treated by EU/RoW oncologists will be tested for the PIK3CA mutation

Conclusions: Impact of ESMO 2014 Presentations on Clinical Practices for HER2+ Breast Cancer

  • US oncologists see nearly 14 HER2+ patients per quarter
    • EU/RoW oncologists see nearly 11 HER2+ patients per quarter
  • Trastuzumab is currently the most commonly used HER2 targeted therapy by EU/RoW oncologists (64%)
    • Trastuzumab and Trastuzumab+Pertuzumab are being equally used (~45%) by US oncologists
    • Impact of the Phase III Cleopatra Study:
      • EU/RoW oncologists are expecting to increase their usage of Trastuzumab + Pertuzumab in the next year for their HER2+ metastatic breast cancer patients (52%) (in all lines of therapy)
      • US oncologists are expecting to decrease their usage of Trastuzumab+Pertuzumab for HER2+ metastatic patients (39%) (in all lines of therapy)
        • US oncologists (64%) are expecting increase usage of Trastuzumab emtansine
        • Impact of the CherLOB Study:
          • The majority of US and EU/RoW oncologists believe the data presented in the CherLOB study is clinically important
          • In the past year, minimal PIK3CA mutation testing by US and EU/RoW oncologists was occurring for HER2+ breast cancer patients (<10%)
          • 31% of early breast cancer patients being treated by US oncologists will be tested for the PIK3CA mutation in the next year
            • 16% of early breast cancer patients treated by EU/RoW oncologists will be tested
  • Over 40% of metastatic breast cancer patients being treated by US oncologists will be tested in the next year
    • 19% of metastatic breast cancer patients being treated by EU/RoW oncologists will be tested for the PIK3CA mutation

For a more detailed analysis report, please click here to download the full report.

Submitted by Jessica Harnisch, Assoc. Global Medical Analyst; Robert Stephan, Sr. Director Medical Services and Strategy; Justin Boag, Consultant; and Jan Heybroek, President MDoutlook.

October 14, 2014 - 08:10 pm Posted in Featured comments0 Comments

ALEXANDRIA, VA – A pre-meeting presscast gives a bird’s eye view of research that will be presented when ASCO’s 2014 Quality Care Symposium meeting swings into full gear in Boston, Mass., this coming Friday.  Separate studies featured at the presscast focused on the influence of sociodemographic factors on treatment selection and mortality, as well as physician and patient factors associated with improved cancer care.

Parental Status and Treatment Choice

A pilot survey of 42 patients indicates that having children influences choice of cancer treatments for patients with advanced cancer (Abstract 65). The majority of parents (64%) in the study indicated that parenthood motivates them to purse life-extending treatment so that they can gain more time with their children. About 15% said that preserving parental functioning was a treatment priority, and 12% cited the importance of receiving treatments close to home rather than travel for a second opinion or have treatment that requires long hospital stays. Interestingly, 24% of respondents did not perceive having children as an influence on their treatment decisions.

About 50% viewed hospice as a supportive resource, taking the burden off of family, and about 21% were not interested in hospice. Respondents seemed to conflate palliative care with end of life care, suggesting an area where more clarification is needed for patients.

These findings suggest that physicians should discuss factors related to parental status with their patients when deciding on a course of treatment. “This study provides some insights into parenting considerations for the first time, and should encourage conversations between oncologists and patients about treatment priorities,” said lead author Devon Check, a PhD candidate at the University of Carolina in Chapel Hill, NC.

This is the first study to ask advanced cancer patients with dependent children directly about the effect of parental status on treatment decision-making.  The researchers are planning a larger study to explore the associations among parental status, parental concerns, and medical decision-making for patients with advanced cancer.

“This study stresses the need to individualize care according to the patient’s circumstances. It would be great to see other studies of this sort,” said presscast moderator Gregory A. Masters, MD, Chair of ASCO’s Cancer Care Communications Committee.

Financial Assistance Improves Adherence

It is well known that adherence to adjuvant hormone therapy improves survival, yet it is suboptimal among women with hormone receptor-positive breast cancer. A large study of more than 23,000 women suggests that Medicare Part D Extra Help program, which provides low-income subsidies for medications, boosts adherence to adjuvant hormonal therapy across the board in racial/ethnic groups and reduces disparities in health care (Abstract 2). These findings suggest that addressing economic barriers to medication access has the potential to reduce disparities in outcomes, especially among racial minority groups.

“Patients are more likely to take their medications if they can afford them. Our study shows that federal policy interventions that help cover out-of pocket costs may be able to reduce the gap in breast cancer outcome between white patients and racial minorities,” stated lead author Alana Biggers, MD, MPH, Medical College of Milwaukee, Wisc.

The study population included 23,299 Medicare Part D enrollees with early-stage breast cancer who received hormone therapy within 1 year of surgery. Overall, 27% were enrolled in the Extra Help low-income subsidy program. Women from racial minority groups were more likely to be enrolled in the program; 70% of black women and 56% of Hispanic women received Extra Help, compared with 21% of white women.

Overall, 3-year adherence rates for hormonal therapy were similar across all races; but in the subgroup not enrolled in the Extra Help program, white women had significantly higher adherence rates (62%) compared with black and Hispanic women (55%). Adherence rates were highest among women receiving the low-income subsidy versus those who did not for all racial groups: 71% for white women versus 62% for white women; 67% versus 55% for black women; 71% versus 55% for Hispanics.

“This interesting study shows that using low-income subsidies can help us understand how these programs support adherence and improve overall survival. Adherence is linked to better care,” Dr. Masters commented.

Tumor Board Participation Improves Outcomes in Certain Cancers

Oncologist participation in weekly tumor board meetings appears to improve survival for patients with stage IV small-cell lung cancer and stage IV colorectal cancers, according to a population-based observational study of almost 5000 patients with lung or colorectal cancer and 1600 oncologists (Abstract 179). Oncologist participation in tumor board meetings also boosted the chances of patient enrollment in clinical trials and increased the likelihood of patients with early-stage non-small cell lung cancer (NSCLC) receiving guideline-based curative surgery.

“These findings are exploratory and will be the basis of future study. Patients with these tumors may want to ask their doctors if their cases will be discussed by a tumor board that includes multidisciplinary experts,” said lead author Kenneth L. Kehl, MD, a fellow in cancer medicine at the University of Texas MD Anderson Cancer Center in Houston.

The study revealed different patterns of oncologist participation in multidisciplinary tumor boards. About 54% participated weekly, 26% participated monthly, 8% participated quarterly.

Dr. Kehl cautioned that this was not a randomized trial, so one should not leap to the conclusion that tumor board participation directly improves survival. The study identifies associations rather than direct effects.

“This study supports our belief that multidisciplinary communication improves outcomes and enrollment in clinical trials. Tumor boards are one educational tool that can improve care for cancer patients and the effect is difficult to measure,” Dr. Masters noted.

Sociodemographic Disparities Affect Death Rates

Being married, having insurance, being white, female gender, younger age, higher education level, higher income level, insurance coverage, and earlier stage of cancer all appear to reduce the likelihood of dying 1 month after cancer-related surgery (Abstract 282) These findings come from a study of more than 1.1 million patients in the SEER database undergoing surgery for the most common or most fatal cancers; among these, 53,498 (4.8%) died within 1 month of surgery.

Previous research suggests that 1-month mortality following surgery is associated with hospital and surgeon volume. Minority race, uninsured status, and low-income level are known factors associated with less likelihood of receiving care at a high-volume, high performance hospital.

A limitation of the study is that SEER does not include data on comorbidity or place of care.

“Our results suggest that there is a lot we can do for all patients to improve outcomes. We can start by identifying and supporting improvements for under performing hospitals as well as proactively offering social support services to patients at high risk of poorer outcomes,” said lead author Brandon A. Mahal, a fourth-year medical student at Harvard Medical School and research fellow at Dana-Farber Cancer Institute in Boston.

“This study highlights special risk groups and emphasizes the need for strong psychosocial support to improve their outcomes,” Dr. Masters said.

ASCO CANCER SURVIVORSHIP CARE PLAN

At the presscast, Deborah A. Mayer, PhD, University of North Carolina, Chapel Hill,  informed listeners about the availability of ASCO’s new streamlined template for a care plan for cancer survivors. This 2-year effort makes the care plan easier to implement and will hopefully transition care from oncologists to primary care physicians for the growing number of cancer survivors who benefit from advances in treatment.  The template is available on the ASCO website.

By Alice Goodman

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