Comorbidity patterns in cancer survivors in the 21st century. Marjan van den Akker

Transcription

1 Comorbidity patterns in cancer survivors in the 21st century Marjan van den Akker

2 Background Comorbidity & multimorbidity concepts relevance methodological challenges Comorbidity in cancer patients somatic mental Department of Family Medicine 2

3 Background Ageing of the population: Cancer incidence Treatment & survival à prevalence Chronic diseases Cancer survivors with comorbidity Department of Family Medicine 3

4 Comorbidity what are we talking about? Department of Family Medicine 4

5 Cancer Valderas et al, 2009 Ann Fam Med Department of Family Medicine 5

6 How frequent is multimorbidity? - 1 Fortin et al, 2012, Ann Fam Med Department of Family Medicine 6

7 How frequent is multimorbidity? % 45% Prevalence of chronic diseases in Flanders (Age standardised rate) 3.17 Millions ³ 1 chronic disease Relative increase since: % +23% 40% 35% Prevalence 30% 25% 20% 15% 10% 5% 0% Year 1.84 Millions ³ 2 chronic diseases 1.13 Millions ³ 3 chronic diseases 0.71 Millions ³ 4 chronic diseases 0.44 Millions ³ 5 chronic diseases +79.9% +40.2% % +56.9% % +76.4% % +98% Intego, 2015 Department of Family Medicine 7

8 % increase of chronic illness , the Netherlands (RIVM, NIVEL) Department of Family Medicine 8

9 Comorbidity of cancer Additional (chronic) diseases, either present at the time of diagnosis, or occurring subsequently to the diagnosis Department of Family Medicine 9

10 Why is comorbidity a problem? 1 Patient Quality of life Treatment burden Informal caregivers Department of Family Medicine 10

11 Why is comorbidity a problem? 2 Professional Difficult to interpret symptoms Multiple (conflicting) guidelines Co-morbidity: we need a guideline for each patient, not a guideline for each disease Dawes, 2010, Fam Pract Regular medication interactions with chemotherapy Department of Family Medicine 11

12 Why is comorbidity a problem? 3 Patient & professional Compliance Shared decision making Department of Family Medicine 12

13 Why is comorbidity a problem? 4 Cancer prognosis Directly: increased physiological burden of disease Indirectly: effects of comorbidity on treatment choice, timeliness and/or effectiveness of treatment Department of Family Medicine 13

14 Why is comorbidity a problem? 5 Research Study population Cancer patients are heterogeneous group RCTs often exclude patients with comorbidity Recruitment of a vulnerable population Koczwara B, ed. Cancer and chronic conditions. Springer, 2016 Department of Family Medicine 14

15 Why is comorbidity a problem? 6 Research Operationalisation and measurement Disease count Comorbidity index CCI à National Cancer Institute CI C3 (cancer specific) ACE-27 Koczwara B, ed. Cancer and chronic conditions. Springer, 2016 Department of Family Medicine 15

16 Why is comorbidity a problem? 7 Research Information morbidity often incomplete Self-reported vs. physician diagnosed EMR Cancer registries Administrative databases Koczwara B, ed. Cancer and chronic conditions. Springer, 2016 Department of Family Medicine 16

17 Knowing all these difficulties, can we still identify patterns? Department of Family Medicine 17

18 Vos et al., BMC Fam Pract, 2015 Department of Family Medicine 18

19 Charlson comorbidity index (CCI) cancer 1 no cancer 1 breast ca 2 CCI 0 60% 85% 7% CCI 1 19% 11% 32% CCI 2+ 21% 5% 61% 1. Hovaldt et al, Br J Cancer, Girones et al, Crit Rev Oncol/Hematol, 2010 Department of Family Medicine 19

20 Number of chronic diseases - 1 # diseases cancer 1 no cancer 1 breast ca 2 controls % 22% 72% 81% 1 24% 24% 24% 17% 2+ 54% 54% 1% 1% 1: chronic diseases from GP registration; # 50 2: chronic diseases self-reported; # 8 1. Deckx et al, J Canc Epidemiol, Schoormans et al, Acta Oncologica, 2015 Department of Family Medicine 20

21 Number of chronic diseases - 1 # diseases cancer 1 no cancer 1 breast ca 2 controls % 81% 1 22% 24% 72% 17% 2+ 24% 54% 24% 1% 3+ 54% 1% 1: chronic diseases from GP registration; # 50 2: chronic diseases self-reported; # 8 1. Deckx et al, J Canc Epidemiol, Schoormans et al, Acta Oncologica, 2015 Department of Family Medicine 21

22 Number of chronic diseases - 2 # diseases Thyroid ca Colorectal ca Hodgkin non-hodgkin 0 25% 25% 46% 29% 1 31% 29% 31% 31% 2+ 44% 46% 23% 40% chronic diseases self-reported; # 14 Vissers et al, J Canc Survivorship, 2013 Department of Family Medicine 22

23 Pre-existing diseases top 5 Cancer (%) No cancer (%) 1. DM Lipid disorders Ischemic HD + angina MI Ischemic HD angina COPD * Dementia * Personality disorder * Deckx et al, J Cancer Epidemiol, 2012 Department of Family Medicine 23

24 Subsequent diseases differences Cancer (%) No cancer (%) DVT (<2yrs) * Hypertension * Lipid disorders * BPH * NS: DM, osteoporosis, COPD, HF, CVA, IHD, dementia Deckx et al, J Cancer Epidemiol, 2012 Department of Family Medicine 24

25 Prevalence (12-month rates) mental disorders Any mood % Any anxiety % Active cancer Cancer survivors No cancer Nakash et al, 2014, PON Department of Family Medicine 25

26 Association incident cancer mental disorder Mental disorder cancer vs. no cancer OR (95% CI) Major depression 3.6 ( ) Drug dependence 3.6 ( ) Agoraphobia 3.3 ( ) Simple phobia 2.5 ( ) NS: dysthymia, bipolar, alcohol dependence, social phobia, panic attack/disorder, generalized anxiety disorder, PTSD Honda et al, 2004, Psychother Psychosom Department of Family Medicine 26

27 Association long-term cancer survival ( 5 yrs) anxiety Mental disorder cancer vs. no cancer OR (95% CI) Any anxiety disorder 1.49 ( ) Specific phobia 1.59 ( ) Medical phobia 3.45 ( ) NS: social anxiety, generalized anxiety, PTSD, panic disorder, agoraphobia Greer et al, 2011, Psychosom Department of Family Medicine 27

28 Prevalence mental disorders cancer patients in acute care hospitals Singer et al, 2010, Ann Oncol Department of Family Medicine 28

29 Cancer, depression and coping Cancer patients avoiding coping à depression active coping à depression (when higher educated) seeking social support à depression () Aarts et al, PON, 2015 Department of Family Medicine 29

30 Points of interest in mental care for cancer patients Treatment gap common mental disorders à screening Explore possibilities to support effective coping strategies Department of Family Medicine 30

31 Wrapping up Many patients with cancer have comorbidity; somatic / mental No information about patterns 2 dis. Importance of comprehensive medical info Treatment and disease interactions Treatment burden for patients Department of Family Medicine 31

32 Department of Family Medicine 32