Comorbidity patterns in cancer survivors in the 21st century Marjan van den Akker
Background Comorbidity & multimorbidity concepts relevance methodological challenges Comorbidity in cancer patients somatic mental Department of Family Medicine 2
Background Ageing of the population: Cancer incidence Treatment & survival à prevalence Chronic diseases Cancer survivors with comorbidity Department of Family Medicine 3
Comorbidity what are we talking about? Department of Family Medicine 4
Cancer Valderas et al, 2009 Ann Fam Med Department of Family Medicine 5
How frequent is multimorbidity? - 1 Fortin et al, 2012, Ann Fam Med Department of Family Medicine 6
How frequent is multimorbidity? - 2 50% 45% Prevalence of chronic diseases in Flanders (Age standardised rate) 3.17 Millions ³ 1 chronic disease Relative increase since: 1994 2000 +40% +23% 40% 35% Prevalence 30% 25% 20% 15% 10% 5% 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 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% +128.8% +56.9% +191.2% +76.4% +256.5% +98% Intego, 2015 Department of Family Medicine 7
% increase of chronic illness 2005-2025, the Netherlands (RIVM, NIVEL) Department of Family Medicine 8
Comorbidity of cancer Additional (chronic) diseases, either present at the time of diagnosis, or occurring subsequently to the diagnosis Department of Family Medicine 9
Why is comorbidity a problem? 1 Patient Quality of life Treatment burden Informal caregivers Department of Family Medicine 10
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
Why is comorbidity a problem? 3 Patient & professional Compliance Shared decision making Department of Family Medicine 12
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
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
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
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
Knowing all these difficulties, can we still identify patterns? Department of Family Medicine 17
Vos et al., BMC Fam Pract, 2015 Department of Family Medicine 18
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, 2015 2. Girones et al, Crit Rev Oncol/Hematol, 2010 Department of Family Medicine 19
Number of chronic diseases - 1 # diseases cancer 1 no cancer 1 breast ca 2 controls 2 0 22% 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, 2012 2. Schoormans et al, Acta Oncologica, 2015 Department of Family Medicine 20
Number of chronic diseases - 1 # diseases cancer 1 no cancer 1 breast ca 2 controls 2 0 22% 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, 2012 2. Schoormans et al, Acta Oncologica, 2015 Department of Family Medicine 21
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
Pre-existing diseases top 5 Cancer (%) No cancer (%) 1. DM 15.3 15.6 2. Lipid disorders 13.2 13.0 3. Ischemic HD + angina 11.9 11.1 4. MI 10.6 9.7 5. Ischemic HD angina 10.3 9.6 COPD 9.9 7.9* Dementia 1.6 2.9* Personality disorder 0.6 1.1* Deckx et al, J Cancer Epidemiol, 2012 Department of Family Medicine 23
Subsequent diseases differences Cancer (%) No cancer (%) DVT (<2yrs) 0.93 0.21* Hypertension 0.37 0.56* Lipid disorders 0.37 0.76* BPH 0.51 1.09* NS: DM, osteoporosis, COPD, HF, CVA, IHD, dementia Deckx et al, J Cancer Epidemiol, 2012 Department of Family Medicine 24
Prevalence (12-month rates) mental disorders Any mood % Any anxiety % Active cancer 8.9 13.5 Cancer survivors 6.0 12.5 No cancer 6.0 11.1 Nakash et al, 2014, PON Department of Family Medicine 25
Association incident cancer mental disorder Mental disorder cancer vs. no cancer OR (95% CI) Major depression 3.6 (1.4-8.8) Drug dependence 3.6 (1.3-9.8) Agoraphobia 3.3 (1.0-10.4) Simple phobia 2.5 (1.0-6.2) 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
Association long-term cancer survival ( 5 yrs) anxiety Mental disorder cancer vs. no cancer OR (95% CI) Any anxiety disorder 1.49 (1.04-2.13) Specific phobia 1.59 (1.06-2.44) Medical phobia 3.45 (1.15-10.0) NS: social anxiety, generalized anxiety, PTSD, panic disorder, agoraphobia Greer et al, 2011, Psychosom Department of Family Medicine 27
Prevalence mental disorders cancer patients in acute care hospitals Singer et al, 2010, Ann Oncol Department of Family Medicine 28
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
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
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
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