Predictors of Palliative Therapy Receipt in Stage IV Colorectal Cancer

Transcription

1 Predictors of Palliative Therapy Receipt in Stage IV Colorectal Cancer Osayande Osagiede, MBBS, MPH 1,2, Aaron C. Spaulding, PhD 2, Ryan D. Frank, MS 3, Amit Merchea, MD 1, Dorin Colibaseanu, MD 1 ACS Quality and Safety Conference July 23rd, Mayo Clinic, Section of Colon and Rectal Surgery, Jacksonville, FL 2 Mayo Clinic, Department of Health Sciences Research, Jacksonville, FL 3 Mayo Clinic, Division of Biomedical Statistics and Informatics, Rochester, MN

2 Disclosures The authors have no disclosures

3 Background Approximately 140,000 Americans will be diagnosed with colorectal cancer in About 20-30% of these will present with metastatic disease 2,3 Early integration of palliative therapy is now considered the standard of care Palliative therapy is associated with prolonged survival, improved quality of life, reduced utilization of hospital resources and decreased health care delivery costs, 4,5 but remains underutilized in stage IV colorectal cancer 1. Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, , National Cancer Institute. Bethesda, MD, based on November 2017 SEER data submission, posted to the SEER web site, April Siegel RL, Miller KD, Fedewa SA, Ahnen DJ, Meester RGS, Barzi A, Jemal A. Colorectal cancer statistics, CA Cancer J Clin 2017;67: Walker MS, Pharm EY, Kerr J, Yim YM, Stepanski EJ, Schwartzberg LS. Symptom burden & quality of life among patients receiving second-line treatment of metastatic colorectal cancer. BMC research notes. 2012;5: Park JH, Kim TY, Lee KH, Han SW, Oh DY, Im SA, Kang GH, Chie EK, Ha SW, Jeong SY, Park KJ, Park JG, Kim TY. The beneficial effect of palliative resection in metastatic colorectal cancer. Br J Cancer 2013;108: Alonso-Babarro A, Astray-Mochales J, Dominguez-Berjon F, Genova-Maleras R, Bruera E, Diaz-Mayordomo A, Centeno Cortes C. The association between in- patient death, utilization of hospital resources and availability of palliative home care for cancer patients. Palliat Med 2013;27:68-75

4 Objective To identify the patient and institutional characteristics associated with increased likelihood of receiving palliative therapy in stage IV colorectal cancer

5 Methods Retrospective cohort analysis of ACS National Cancer Database (NCDB) a national cancer registry with more than 1,500 accredited cancer programs captures >70% of newly diagnosed cancer cases in the United States Deceased patients treated for Stage IV colorectal cancer ( ) were identified within the NCDB Patients were classified based on their length of survival (< 6 months, 6-24 months, and 24+ months) to provide timing context Multivariable logistic regression was used to evaluate patient and hospital characteristics associated with increased likelihood of palliative therapy

6 Methods (cont d) Patient characteristics age year of diagnosis sex race/ethnicity primary insurance payer median income percentage with no high school diploma distance from the treating institution Charlson-Deyo comorbidity score Exclusion Criteria: stage 1, 2, 3 or unknown stage cancer patients treated in hospitals in which < 0.5% colorectal cancer patients received palliative therapy (due to low availability) Hospital characteristics teaching status urban or rural location US geographic region

7 Results A total of 85,981 patients with stage IV colorectal cancer were analyzed Approximately 11% received palliative therapy For patients who survived between 6 and 24 months, factors associated with higher odds of palliative therapy include: Medicaid insurance or an uninsured status High income (annual income of $63,000+) Mountain and Pacific regions of the US

8 Results (Cont d) For patients who survived < 6months, factors associated with increased likelihood of palliative therapy include: a younger age academic hospitals, residence within miles or > 45 miles from treating institutions A more recent year of diagnosis was associated with increased likelihood of palliative therapy for all survival durations

9 Multivariate Associations between Palliative Therapy Receipt and Patient Characteristics Using Logistic Regression in Deceased Patients with Stage IV Colorectal Cancers Stratified by Duration of Survival Odds Ratio (95% CI) Covariate a <6 months 6-24 Months >24 Months Age 0.92 (0.88, 0.95) d 0.96 (0.92, 1.01) 1.03 (0.95, 1.12) Year of Diagnosis 1.15 (1.12, 1.18) d 1.18 (1.15, 1.22) d 1.25 (1.18, 1.32) d Male (ref Female) 1.01 (0.94, 1.08) 1.06 (0.98, 1.14) 0.92 (0.81, 1.04) Race/Ethnicity (ref White) Black 0.99 (0.89, 1.09) 1.09 (0.97, 1.22) 1.09 (0.89, 1.33) Hispanic 1.21 (0.99, 1.47) 1.14 (0.92, 1.41) 1.17 (0.82, 1.66) Asian 0.98 (0.74, 1.28) 1.11 (0.84, 1.48) 0.81 (0.47, 1.38) Other/Unknown 0.80 (0.60, 1.08) 1.03 (0.76, 1.40) 0.66 (0.36, 1.19) Primary Payer (ref Private) Medicaid 0.97 (0.83, 1.14) 1.23 (1.06, 1.44) c 1.08 (0.83, 1.41) Medicare 0.96 (0.87, 1.06) 1.10 (0.98, 1.22) 0.87 (0.73, 1.04) Other Government 0.80 (0.53, 1.21) 1.32 (0.88, 1.98) 1.14 (0.58, 2.23) Not Insured 1.16 (0.98, 1.36) 1.38 (1.16, 1.65) d 0.97 (0.70, 1.32) Insurance Status Unknown 0.87 (0.65, 1.17) 0.60 (0.40, 0.91) b 0.77 (0.41, 1.44) Median Income Quartiles (ref <$38k) $38,000-$47, (0.93, 1.14) 1.08 (0.96, 1.21) 1.10 (0.90, 1.34) $48,000-$62, (0.94, 1.18) 1.11 (0.97, 1.27) 1.00 (0.80, 1.25) $63, (0.94, 1.24) 1.24 (1.05, 1.46) b 1.03 (0.79, 1.35) Percentage with no High School Degree ( ) 1.03 (0.98, 1.07) 1.00 (0.94, 1.05) 0.99 (0.91, 1.08) Great Circle Distance (ref <2), mi (0.93, 1.19) 1.04 (0.89, 1.20) 1.00 (0.78, 1.28) (0.97, 1.21) 1.07 (0.93, 1.22) 0.93 (0.74, 1.16)

10 Multivariate Associations (Cont d) (1.00, 1.26) 1.02 (0.89, 1.18) 0.89 (0.71, 1.12) (1.10, 1.45) d 1.01 (0.86, 1.19) 0.94 (0.73, 1.21) > (1.05, 1.47) b 0.92 (0.76, 1.11) 0.81 (0.60, 1.09) Urban/Rural 2013 (ref Metro >1 million) Metro 250k to 1 million 0.95 (0.87, 1.04) 1.03 (0.93, 1.14) 1.08 (0.91, 1.28) Metro fewer than 250k 0.93 (0.83, 1.05) 1.05 (0.92, 1.20) 1.09 (0.88, 1.35) Urban > 20k adjacent to metro 0.99 (0.84, 1.17) 1.08 (0.89, 1.30) 1.23 (0.92, 1.64) Urban > 20k not adjacent to metro 1.17 (0.89, 1.55) 1.25 (0.93, 1.69) 1.36 (0.84, 2.19) Urban 2.5k to 19.9k adjacent to metro 0.95 (0.80, 1.12) 1.24 (1.03, 1.49) b 1.10 (0.81, 1.49) Urban 2.5k to 19.9k not adjacent to metro 1.07 (0.86, 1.34) 1.12 (0.88, 1.43) 1.34 (0.91, 1.99) Rural / urban <2.5k adjacent to metro 0.82 (0.58, 1.17) 0.93 (0.61, 1.42) 1.05 (0.57, 1.93) Rural / urban <2.5k not adjacent to metro 0.93 (0.67, 1.28) 1.47 (1.03, 2.09) b 0.49 (0.19, 1.25) Charlson-Deyo Score 0.97 (0.93, 1.02) 1.05 (0.98, 1.11) 0.97 (0.87, 1.09) Geographic region (ref East Coast) Central 1.04 (0.97, 1.12) 0.99 (0.92, 1.08) 0.90 (0.79, 1.03) Mountain 1.17 (0.97, 1.42) 1.31 (1.07, 1.61) c 1.28 (0.91, 1.81) Pacific 1.50 (1.30, 1.72) d 1.23 (1.05, 1.45) b 1.11 (0.84, 1.48) Academic Program (ref Nonacademic Program) 1.16 (1.07, 1.25) d 1.09 (1.00, 1.19) b 0.97 (0.84, 1.12) Grade 1.05 (1.03, 1.06) d 1.07 (1.06, 1.08) d 1.08 (1.05, 1.10) d b P < 0.05; c P < 0.01; d P < a The following were modeled ordinally: age categories (<50, 50-64, 65-74, 75-84, 85 years); year of diagnosis in 2-year categories ( ); percentage with no high school diploma categories ( 21%, 13%-20%, 7%-12%, <7%); Charlson-Deyo score categories (0, 1, 2); grade categories for differentiation (well, moderately, or poorly, and undifferentiated). The logistic model included all covariates listed in the table.

11 Limitations Retrospective nature of study insufficient for proving causality The NCDB does not differentiate between specialized palliative care, and interventions provided in a palliative manner by treating surgeons or physicians, but likely captures both modalities

12 Conclusions Our study indicates that palliative therapy in stage IV CRC is greater among more recently diagnosed patients, Medicaid and uninsured patients, academic centers, and Mountain and Pacific regions of the United States. The significance of these factors appears to differ by survival duration. Additional studies are needed to investigate factors mediating greater use of palliative therapy among Medicaid and uninsured patients, as well as in the Mountain and Pacific regions of the United States