Caring for cancer patients with comorbidity. Chair: Associate Professor Diana Sarfa3

Transcription

1 Caring for cancer patients with comorbidity Chair: Associate Professor Diana Sarfa3

2 Why do we care? Comorbidity: is common among cancer pa3ents. has a major impact on pa3ents. has a major impact on health services. Is an important driver of inequi3es. the effects of comorbidi3es are modifiable.

3 Aims of symposium: 1) To describe how cancer and other chronic condi3ons interact, and how comorbidity can be measured in cancer pa3ent popula3ons. 2) To provide up to date Australian and New Zealand evidence rela3ng to the prevalence and impact of comorbidity among cancer pa3ents. 3) To describe research rela3ng to the impact of comorbidity on pa3ents, and on clinical decision- making. 4) To describe an approach to reduce adverse outcomes among cancer pa3ents due to drug regimes that do not take account of comorbidity and other pa3ent factors. 5) To describe an interven3on designed to assist in the management of cancer pa3ents with complex health needs and enhance self- management.

4 How does comorbidity interact with cancer? Associate Professor Diana Sarfa3

5 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

6 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

7 Why do cancer and other chronic condi3ons co- exist? Cancer and other condi3ons share common risk factors Comorbidity may cause cancer Comorbidity may protect from cancer There may be common gene3c or physiological pathways between cancer and comorbidity.

8 Why do cancer and other chronic condi3ons co- exist? Cancer and other condi3ons share common risk factors Comorbidity may cause cancer Comorbidity may protect from cancer There may be common gene3c or physiological pathways between cancer and comorbidity.

9 Common risk factors

10 Why do cancer and other chronic condi3ons co- exist? Cancer and other condi3ons share common risk factors Comorbidity may cause cancer Comorbidity may protect from cancer There may be common gene3c or physiological pathways between cancer and comorbidity.

11 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

12 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

13 A mul3choice ques3on. There is evidence from high quality studies that: a. Pa3ents with comorbidity tend to have their cancer diagnosed earlier than those without. b. Pa3ents with comorbidity tend to have their cancer diagnosed later than those without. c. Pa3ents with comorbidity tend to have their cancer diagnosed at around the same 3me as those without. d. All of the above.

14 A mul3choice ques3on. There is evidence from high quality studies that: a. Pa3ents with comorbidity tend to have their cancer diagnosed earlier than those without. b. Pa3ents with comorbidity tend to have their cancer diagnosed later than those without. c. Pa3ents with comorbidity tend to have their cancer diagnosed at around the same 3me as those without. d. All of the above.

15 Impact on diagnosis Compe3ng demands hypothesis Surveillance hypothesis Death from other causes hypothesis Fleming 2006

16 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

17 Another mul3choice ques3on. There is evidence from high quality studies that: a. Pa3ents with comorbidity tend have to have more treatment for their cancer than those without. b. Pa3ents with comorbidity tend have to have less treatment for their cancer than those without. c. Pa3ents with comorbidity tend have to have similar treatment for their cancer than those without. d. All of the above.

18 Another mul3choice ques3on. There is evidence from high quality studies that: a. Pa3ents with comorbidity tend have to have more treatment for their cancer than those without. b. Pa3ents with comorbidity tend have to have less treatment for their cancer than those without. c. Pa3ents with comorbidity tend have to have similar treatment for their cancer than those without. d. All of the above.

19 Impact on treatment Why? Concern by clinician that treatment may be less effec3ve among those with comorbidity Concern by clinician or pa3ent that comorbidity will increase toxicity of treatment. Life expectancy is insufficient to jus3fy treatment Pa3ent more likely to decline treatment

20 Impact on treatment 190 pa3ents with stage III colon cancer Those with comorbidity were considerably less likely to receive chemotherapy 84% without comorbidity (Charlson comorbidity score=0) cf 19% with comorbidity (Charlson comorbidity score of 3+) Among those with highest comorbidity there was around a 60% reduc3on in excess risk of death if offered chemotherapy. Sarfati D, Hill S et al. The effect of comorbidity on the use of adjuvant chemotherapy and survival from colon cancer: a retrospective cohort study. BMC: Cancer. 2009: 9; 16.

21 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

22 Impact on survival Comorbidity has been found to have an adverse impact on survival in every cancer site inves3gated.

23 Impact on survival: Why does comorbidity affect survival Direct effect Indirect effect because of reduced cancer treatment Effect of comorbidity on cancer progression Recurrence more likely in those with diabetes even in context of RCT (Meyerhardt et al 2003)

24 Impact on other outcomes Quality of life Costs of care

25 How does cancer interact with comorbidity Why do cancer and other chronic condi3ons coexist? How does comorbidity impact on: Diagnosis of cancer? Treatment for cancer? Outcomes from cancer? Inequali3es in outcomes from cancer?

26 Not all good news (inequi3es) Soeberg M, Blakely T, Sarfati D et al (2012). Cancer Trends: Trends in Survival by Ethnic and Socioeconomic Group, New Zealand Wellington: University of Otago and Ministry of Health.

27 Ethnic inequi3es in colon cancer survival 40% Excess mortality risk (Maori/non-Maori) 30% 20% 10% Comorbidity and treatment/health service factors each accounted for a third of the survival difference. 0% Unadjusted Demographics + Disease factors + Patient factors Risk adjustments + Treatment + Health service access Hill S, Sarfa3 D et al. Cancer. 2010: 116;

28 Two C3 projects: Effect of comorbidity on care and cancer survival inequali3es (C3 Quant) Cancer care journeys and clinical decision- making (C3 Qual)

29 The C3 Studies: Cancer, Comorbidity and Care MoH Na'onal Health Board Cancer Registry (n=14,096) Study Cohort Ethnicity Hospitalisa3on and other Databases Mortality Database Notes Review (Upper GI & Rectal, n=718) Demographics Tumour Comorbidity Health Care Survival

30 Measuring Comorbidity 1. No gold standard exists. 2. Measure depends on: 1. Specificity vs generalisability requirements 2. Data availability 3. Resource availability 4. Study ques3ons 3. Recommenda3ons: 1. Administra3ve data (large popula3ons) 2. Inclusive of condi3ons 3. More than one data source

31 Sarfa3 D, Gurney J, Stanley J, et al J Clin Epidemiol 2014; 67(5): Sarfa3 D, Gurney J, Stanley J, et al Medical Care; 2014; 52(7): Two approaches to measuring comorbidity in cancer popula3ons Hospitalisa3on data for 5 years prior to diagnosis Pharmaceu3cal data in year* prior to diagnosis Iden3fica3on of all important concurrent condi3ons that were likely to have an impact on func3on or length of life Iden3fica3on of all important concurrent condi3ons that were likely to have an impact on func3on or length of life n=50 condi3ons C3 Index n=19 condi3ons PBCI *excl 3 months immediately prior

32 The C3 Index: is a cancer- specific compila3on of comorbid condi3ons, weighted according to their associa3on with non- cancer death. Sarfa%, Gurney, et al. J Clin Epi (font sizes = condi3on weights)

33 Selected findings from the C3 Study Dr Jason Gurney

34 MoH Na'onal Health Board Cancer Registry (n=14,096) Hospitalisa3on and other Databases Mortality Database Notes Review (Upper GI & Rectal, n=718) Study Cohort Ethnicity Demographics Tumour Comorbidity Health Care Survival

35 Comorbidity is highly- prevalent among cancer pa3ents but prevalence varies by cancer type.

36 Stomach Liver Colon Bladder Kidney Uterine Rectal Combined Sites Ovarian Breast Hypertension (Primary) Crude Prevalence (%) COPD/Asthma Liver Stomach Uterine Kidney Colon Bladder Combined Sites Rectal Ovarian Breast Diabetes (Any) Crude Prevalence (%) Cardiac Arrhythmia Stomach Stomach Bladder Liver Liver Bladder Rectal Colon Colon Kidney Kidney Rectal Combined Sites Combined Sites Uterine Uterine Breast Ovarian Ovarian Breast Crude Prevalence (%) Sarfa%, Gurney, et al. (2013). Asia- Pac J Clin Oncol Crude Prevalence (%)

37 Māori cancer pa3ents tend to have a greater comorbidity burden.

38 Hypertension (Primary) Stomach Bladder Liver Breast Rectal Colon Uterine Combined Sites Kidney Ovarian Non- Māori Māori Crude Prevalence (%)

39 Hypertension (Primary) Stomach Bladder Liver Breast Rectal Colon Uterine Combined Sites Kidney Ovarian Non- Māori Māori Crude Prevalence (%)

40 Diabetes (Any) Kidney Uterine Stomach Colon Bladder Combined Sites Ovarian Rectal Liver Breast Non- Māori Māori Crude Prevalence (%)

41 Diabetes (Any) Kidney Uterine Stomach Colon Bladder Combined Sites Ovarian Rectal Liver Breast Non- Māori Māori Crude Prevalence (%)

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44 A high comorbidity burden increases likelihood of mortality

45 Blood Disorders Diabetes (With Complica'ons) Gyn Urological Breast Colorectal Upper GI Conges've Heart Failure (Condi%on causes death, even aeer adjus%ng for covariates) Gyn Breast Colorectal Urological Upper GI Hypertension Urological Gyn Colorectal Breast Upper GI Gyn Colorectal Urological Breast Upper GI Adjusted* All- Cause Excess Mortality (%) *For age, sex, site, stage

46 Using the C3 Index, we aggregate pa3ent comorbidity into one cancer- specific score which is very useful when you want to present a lot of informa3on at once.

47 Breast Urological C3 Index Category 1 0 (Ref) Colorectal 1 0 (Ref) Gynaecological 3 Upper GI (Ref) 0 (Ref) 0 (Ref) Adjusted* All- Cause Excess Mortality (%) *For age, sex, site, stage

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49 Does comorbidity influence treatment receipt?

50 Upper GI Stage I- III Surgery C3 Index Category Adjusted* Odds Ra'o: 0.50 ( ) Received Cura've Surgery (%) *For age, sex, site, ethnicity, depriva'on

51 Summary Comorbidity is highly- prevalent among cancer pa3ents but prevalence varies by cancer type.

52 Summary A high comorbidity burden increases likelihood of mortality. ( and reduces likelihood of treatment )

53 Summary The C3 Index is a valid, cancer- specific aggregate measure of comorbidity that uses rou3nely- collected hospitalisa3on data.

54 C3 Quant Inves3gators Effect of comorbidity on cancer and cancer survival inequali'es Diana Sarfa3 (PI) Jason Gurney Chris Cunningham James Stanley Lis Ellison- Loschmann Jonathan Koea Liz Dennet Andrew Simpson Tony Blakely Clare Salmond Virginia Signal Ruth Cunningham Esther Swart Josh Chamberlain Bee Lim Clare McSherry Jennifer Haubrock Ken Richardson Nasser Bagheri

55 Where to next?

56 Where to next? Comorbidity Impacts treatment receipt and cancer outcomes Ensuring adequate cancer treatment for those with comorbidity Ensure adequate comorbidity treatment for those with cancer Considering measuring/ monitoring comorbidity