Health status and Healthcare utilization of Breast cancer survivors

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1 Health status and Healthcare utilization of Breast cancer survivors Jihyoun Lee Breast Center, department of surgery Soonchunhyang University Seoul Hospital

2 Issues in cancer survivors Persistent and late effects of breast cancer treatment the Study of Multi disciplinary Teamwork for breast cancer survivorship (SMARTSHIP) Nationwide database of breast cancer survivors

3 In fact, most patients who are diagnosed with cancer today will not die from it. A shift in the understanding of cancer from a once fatal disease to a long term chronic diseases 70% of survivors experience comorbid conditions, and more than 30% having two or more comorbid diseases

4 Age dependent changes of cancer survivors vs siblings Hudson et al. J Clin Oncol (2015)

5 Sociodemographic, cancer therapy, and health behaviors affecting health status domains Risk factors by health status domains Poor general health Adverse mental health Cancer related pain Cancer related anxiety High (5 6 domains) Female Low education/income level Alkylating agent Smoker Low physical activity Obese Intermediate (3 4 domains) Underweight Anthracycline Cystectomy Age 25 years Cranial radiation 30 Gy Lower extremity amputation Craniotomy Low (1 2 domains) Nonwhite race/ethnicity Chest radiation Upper extremity amputation Abdominal radiation > 35 Gy Thoracotomy Hudson et al. J Clin Oncol (2015)

6 Age dependent changes of cancer survivors vs siblings Prevalent ratio for adverse outcomes by chronic condition status Variable General Health Mental Health Cancer related pain Cancer related anxiety PR (95% CI) PR (95% CI) PR (95% CI) PR (95% CI) Second malignancy 1.80 ( ) 1.22 ( ) 1.29 ( ) 1.70 ( ) Vision/hearing/speech 1.69 ( ) 1.47 ( ) 1.35 ( ) 1.15 ( ) Endocrine 1.24 ( ) 1.41 ( ) 1.26 ( ) 1.24 ( ) Respiratory 3.10 ( ) 2.63 ( ) 2.57 ( ) 2.14 ( ) Cardiac 2.72 ( ) 1.72 ( ) 1.31 ( ) 1.23 ( ) gastrointestinal 1.44 ( ) 1.29 ( ) 1.30 ( ) 1.48 ( ) Renal 1.78 ( ) 1.55 ( ) 1.09 ( ) 0.98 ( ) Musculoskeletal 1.15 ( ) 1.05 ( ) 3.20 ( ) 1.10 ( ) Neurologic 2.19 ( ) 2.13 ( ) 2.48 ( ) 1.59 ( ) Other hematologic 1.49 ( ) 1.30 ( ) 1.39 ( ) 1.21 ( ) Hudson et al. J Clin Oncol (2015)

7 Survey conducted in 100 breast and gynecological cancer survivors (FCS) and age, education, marital status matched non cancer controls(ncc) Phillips Salimi et al. Support Care Cancer (2013)

8 Management of chronic comorbidities and preventive care Variable Controls (%) Survivors (%) No. P One visit every 6 mos for patients with chronic stable angina <0.01 Visit every 6 mos for patients with congestive heart failure <0.001 Visit every 6 mos for patients with COPD <0.001 Visit every yr for patients with diagnosis of transient ischemic attack NS Cholesterol test every 6 mos for patients hospitalized for acute NS myocardial infarction and who have hypercholesterolemia Lipid profile 1 yr after initial diagnosis of angina Visit every 6 mos for patients with diabetes Eye examination every yr for patients with diabetes Glycosylated hemoglobin or fructosamine every 6 mos for patients with diabetes Influenza vaccination ,543 <0.001 Cholesterol screening ,543 <0.001 Assessment of visual impairment every 2 yrs ,543 <0.001 Mammography in female patients age 76 yrs Cervical screening in female patients ,018 <0.001 Bone densitometry in female patients ,018 <0.001 Earl et al. Cancer (2004)

9 Surveillance for breast cancer survivors Breast cancer surveillance History and physical examination every 4 to 6 months for 5 years, then annually Mammography annually Second primary cancer risk Complications from disease and treatment Increased risk of second primary breast cancer in ipsilateral and contralateral breasts Increased risk of ovarian and colorectal cancers Increased risk of endometrial cancer if tamoxifen is used (recommended gynecologic examination annually if uterus present) Lymphedema; ovarian failure; endometrial cancer; sexual dysfunction; cardiac and pulmonary toxicities; osteopenia Bone mineral density testing at initiation of aromatase inhibitor therapy and periodically throughout therapy Willbur et al. Am Fam Physician (2015)

10 Late effects? Late effects refer specifically to unrecognized toxicities that are absent or subclinical at the end of therapy and become manifest later with the unmasking of hitherto unseen injury because of any of the following factors: developmental processes, the failure of compensatory mechanisms with the passage of time, or organ senescence. Long term effects refer to any side effects or complications of treatment for which a cancer patient must compensate; also know as persistent effects, they begin during treatment and continue beyond the end of treatment. Late effects, in contrast, appear months to years after the completion of treatment **consequences of cancer and its treatment, regardless of their date of onset**

11 Late effects of breast cancer treatment Institute of medicine (IOM) report 2006 Quality of life Cancer recurrence Psychosocial distress Lymphedema Reproductive/sexual function Osteoporosis Musculoskeletal complaints Cardiovascular Disease Fatigue Cognitive Effects Hill et al., 2014 Lymphedema, osteopenia, osteoporosis, heart disease Agrawal, 2014 Cardiac morbidity, Reproductive function, Bone health, Pulmonary, Breast cosmesis Ewartz et al., 2011 pain, lymphedema, neuropathy, fertility, menopausal symptoms, cardiovascular disease, quality of life

12 Women with invasive breast cancer and women with no cancer history recruited for a cancer research cohort a mailed questionnaire at a median of 10 years post diagnosis or matched reference year 2535 women with breast cancer 2429 women without cancer Hill et al. Breast Cancer Res Treat (2014)

13 Hill et al. Breast Cancer Res Treat (2014)

compared the information with that of female

14 health information provided by 814 breast cancer survivors whose cancer was diagnosed 15 years earlier compared the information with that of female survivors of other cancers Stava et al. Clin Breast Cancer (2014)

A significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported. Segerstrom et al.,1991 Sample size (dropout rate) 100 (7%) Maunsel 223 (13%) et al.

15 A significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported. Segerstrom et al.,1991 Sample size (dropout rate) 100 (7%) Maunsel 223 (13%) et al., 1991 Tasmuth et al., (12%) Hack et al., (11%) Treatment MRM, with/without RT(chest wall and/or axilla) BCT, MRM BCT, MRM, with/without RT(chest wall and/or axilla) BCT, MRM, with/without RT on chest wall Relationship late morbidity with ADL/QOL Edema with function impairment ROM with function impairment No. of arm problems and psychological distress Pain with ADL Chronic symptoms with anxiety/depression Pain with QoL Pain with mental health p<0.01 p<0.01 p<0.001 p<0.01 p<0.001 p<0.001 p<0.001

16 breast cancer survivor cohort(stage I IIB, age 65) who survived at least 5 years (n=1361) breast cancer free comparison cohort on care setting, age, and calendar time. (n=1361) Over 10 years of follow up The median of 564 adjusted HRs equaled 1.06 (IQR ) Lash et al. Breast Cancer Res Treat (2014)

17 Long term cancer survivors Is that what they really are?

18 the Study of Multi disciplinary Teamwork for breast cancer survivorship (SMARTSHIP) Korean Breast Cancer Survivorship Research Group

19 The SMARTSHIP group

20 The SMARTSHIP group Development of care guidelines and delivery system for Korean breast cancer survivors Multi disciplinary research on lifestyle factors in Korean breast cancer patients Development of survivorship care plan through the analysis of unmet needs in Korean breast cancer survivors Bone health status in Korean long term breast cancer survivors Second primary cancer development in breast cancer survivors

21 A nationwide database of breast cancer patients Big Data Breast cancer survivorship research using National Health Insurance Claim data National Health Insurance Service (NHIS) in Korea is a single payer program and is mandatory for all residents in Korea NHIS can be the best national indicator of health issues

22 A nationwide database of breast cancer patients Limitations do not include uninsured events that approximately 28% of total healthcare expenditure occurred in the non reimbursed field. may not be consistent with actual diagnosis because it is basically made for claim purposes. did not fully provide scientific research data consumption of over the counter drugs without medical prescription also cannot be determined

23 Preliminary study : Health status of long term breast cancer survivors the Korea National Health and Nutrition Examination Survey (KNHANES) Database Random selection of representative households per district Face to face interviews of lifestyle and nutrition status Medical examination including laboratory test, chest ray, and BMD

24 Study population( ) (N= ) Excluded(n=27967) Sex=M age<20 cancer survivors other than breast ca breast cancer survivors less than 5 yrs n= Long term breast cancer survivors N=90 Non cancer controls (1:4 ratio) Matched by age and survey year

25 Baseline characteristics Breast cancer survivors N(%) Non cancer controls N(%) Age a (16.7) 60(16.7) (31.1) 112(31.1) (30.0) 108(30.0) (18.9) 68(18.9) 80 3(3.3) 12(3.3) Menopause 0.13 Premenopausal 6(10.3) 42(18.8) Postmenopausal 52(89.7) 182(81.3) Pregnancy 0.70 Ever 55(94.8) 216(96.4) Never 3(5.2) 8(3.6) Age at 1 st pregnancy * 25.20(±3.63) 24.63(±3.89) 0.33 Breast feeding 0.02 Ever 45(81.8) 200(92.6) Never 10(18.2) 16(7.4) Area of Residence 0.33 Urban 67(74.4) 249(69.2) Rural 23(25.6) 111(30.8) Monthly income st quartile 13(14.6) 89(25.4) 2 nd quartile 32(36.0) 85(24.2) 3 rd quartile 18(20.2) 97(27.6) 4 th quartile 26(29.2) 80(22.8) Education 0.11 High school 77(85.6) 320(91.2) college 13(14.4) 31(8.8) p

26 Health status of breast cancer survivors and non cancer controls Breast cancer survivors N(%) Non cancer controls N(%) Self estimated Health Status 67.91(±17.20) 44.84(±21.47) 0.14 Cardiovascular Diseases Hypertension 34(37.8) 125(35.6) 0.70 Myocardial infarction 0(0.0) 4(1.1) 0.57 Angina 2(2.2) 12(3.4) 0.74 Dyslipidemia 14(15.6) 50(14.2) 0.75 Musculoskeletal Pain c 22(43.1) 71(35.9) 0.34 Depression 4(4.4) 14(4.0) 0.77 BMD 0.12 Normal 3(7.7) 17(11.9) Osteroporosis 23(59.0) 58(40.6) Osteopenia 13(33.3) 68(40.6) p

27 Lifestyles of long term breast cancer survivors Breast cancer survivors N(%) Non cancer controls N(%) Smoking 0.87 Nonsmoker 83(92.2) 327(92.9) Past smoker 2(2.2) 6(1.7) Current smoker 5(5.6) 19(5.4) Alcohol Drinking 0.24 nondrinking 34(44.2) 96(34.5) social drinking 43(55.8) 179(64.4) Risky drinking * 0 3(1.1) Physical activity 0.12 High 83(92.2) 303(86.1) Low 7(7.8) 49(13.9) p

28 Health status of breast cancer survivors and non cancer controls

29 Health status of breast cancer survivors and non cancer controls

30 A nationwide database of breast cancer patients Breast cancer survivorship research using National Health Insurance Claim data Breast cancer incidence and treatment trends within 1 year after diagnosis ( ) compared with Korea Central Cancer Registry (KCCR) Courtesy from Dr. Ho H. National health insurance service Ilsan hospital SMARTSHIP group

31 Year Annual incidence of breast cancer diagnosis Invasive cancer (C50 and V193) In situ cancer (D05 and V193) Available data used for removing prevalent cases ( ) Total National Central Cancer Registry 2005 D05 and V193 D05 and V193 C , ,189 10, , ,441 11, , ,494 12, , ,467 13, ,660 1,174 1,072 17,732 14, ,111 1,420 1,290 19,401 16, ,176 1,523 1,400 19,576 16, ,221 1,752 1,622 20,843 17, ,309 1,857 1,727 22,036 Not available ,408 2,017 1,833 23,241 Not available Total 170,473 13,005 11, ,420

32 Annual incidence of breast cancer diagnosis 25,000 20,000 15,000 12,521 13,692 14,754 15,621 16,660 18,111 18,176 19,221 20,309 21,408 Invasive cancer In situ cancer 10,000 5, ,072 1,290 1,400 1,622 1,727 1,

33 Age distribution of breast cancer diagnosis in ,000 3,725 3,530 National Cental Cancer Registry National Health Insurance Claim data 3,500 3,000 2,898 3,309 3,147 2,563 2,500 2,768 2,000 2,220 1,637 1,500 1,000 1,278 1,297 1,378 1,

34 Age distribution of breast cancer diagnosis (NCCR) Park et al. J Breast Cancer (2017)

35 % Treatment trends of breast cancer either adjuvant or palliative Endocrine treatment % chemotherapy 60 No 60 No 40 Yes 40 Yes Radiotherapy % % Operation 60 No 60 No 40 Yes 40 Yes

36 Initial choice of treatment modalities after breast cancer diagnosis % No treatment Encodrine Chemotherapy Radiothearpy Operation Trastuzumab

37 Prescription rate of trastuzumab either adjuvant or palliative % No Yes

38 Prescription patterns in endocrine therapy Overall Age 50 9,000 4,000 8,000 7,000 3,500 3,000 2,849 3,067 3,340 6,000 5,000 4,000 3,000 2,000 2,500 2,000 1,500 1, ,199 1,338 1,538 2,198 2,471 1, anastrozole letrozole tamoxifen toremifen

39 Prescription rates of endocrine drugs Overall Age 50 % % anastrozole letrozole tamoxifen toremifen

40 Annual use of chemotherapeutic agents in prevalent cases 50,000 45,000 40,000 35,000 30,000 25,000 20,000 docetaxel doxorubicin hydrochloride paclitaxel 15,000 10,000 5,

41 The SMARTSHP group: Further research for survivorship Breast cancer survivorship research using National Health Insurance Claim data Second primary cancer development Cardiovascular late effects of breast cancer treatment Pregnancy and childbirth issues

42 The SMARTSHP group: Further research for survivorship Breast cancer survivorship research using National Health Insurance Claim data Depression in Korean breast cancer patients The influence of metabolic syndrome on the incidence and prognosis of breast cancer (Health Screening DB)

43 Summary Management of chronic disease can be important as much as cancer treatment in long term cancer survivors. More attention should be paid about persistent and late effects of breast cancer treatment. An overview of current practice of breast cancer treatment using nationwide database showed promising result for the future survivorship research

44 Thank you for your attention

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