Transcript of "Adherence to Surveillance Care Guidelines After Breast and Colorectal Cancer Treatment with Curative Intent SALLOUM"
Adherence to Surveillance Care Guidelines After Breastand Colorectal Cancer Treatment with Curative IntentRamzi G Salloum, PhDDepartment of Health Policy & Management, University of North Carolina at Chapel HillCenter for Health Policy and Health Services Research, Henry Ford Health System18th Annual HMORN Conference – Seattle, WA – 1 May 2012
Adherence to Surveillance Care Guidelines Ramzi G Salloum, PhD Mark C Hornbrook, PhD Paul A Fishman, PhD Debra P Ritzwoller, PhD Maureen C O’Keeffe Rosetti, MS Jennifer Elston Lafata, PhD Funding: NCI Grant No. R01 CA114204, PI: Mark Hornbrook, PhD Medical Care Burden of Cancer: System and Data Issues NCI Grant No. R25 CA116339, Co-PIs: Peggy Leatt, PhD and Bryan Weiner, PhD Cancer Care Quality Training Program (Ramzi Salloum) 2
Background In 2006, the IOM recommended cancer survivors receive ongoing surveillance care based on a clearly and effectively explained follow-up plan. Evidence- and consensus-based guidelines from NCCN, ASCO, and others outline recommended schedules for ongoing surveillance care after cancer treatment with curative intent. Prior studies found deviations in surveillance care patterns relative to evidence-based guidelines and variations by sociodemographic characteristics. Studies have been mostly limited to 1 delivery organization or Medicare (care received by survivors aged ≤64 years is not well documented). To our knowledge no such studies have been conducted since the IOM report. 3
Aims Evaluation of extent to which surveillance care use was consistent with guideline recommendations Cohorts of breast and colorectal cancer adult survivors 4 geographically diverse health maintenance organizations GHC HFHS KPCO KPNW Study period: 2000-2008 Of specific interest was the evaluation of variability in surveillance care use by age at diagnosis. 4
Study population Inclusion criteria In situ, localized, and regional stage breast and colorectal cancer Patients aged ≥18 years, diagnosed between 2000 and 2008 1-year minimum continuous health plan enrollment prior to diagnosis Exclusion criteria Previous diagnosis of invasive cancer Did not receive treatment with curative intent Females with bilateral mastectomy (breast cancer cohort) Index date 3 months after curative surgical procedure End date Death, tumor recurrence, diagnosis of 2nd primary, health plan disenrollment, 5 years after diagnosis, or end of follow-up 5
Surveillance care receipt 3 distinct types of surveillance testing: Physical examinations Testing for local recurrence Mammography, MRI, ultrasound (for breast cancer) Colonoscopy, sigmoidoscopy, barium enema (for colorectal cancer) Testing for metastatic disease Chest radiograph Chest, abdomen, pelvis or head CT Chest, abdomen, pelvis or head MRI Bone, gallium, liver/spleen scan Abdominal or pelvic ultrasound 6
Analytic approach Estimated time (in days) from index date to receipt of minimum recommended surveillance test 2 physical exams and 1 mammogram 2 physical exams and 1 complete exam of the colon Percentage of patients who received recommended care within 18 months of index date Kaplan-Meier estimates to evaluate median time to initial and subsequent care receipt by type of examination/test Cox proportional hazards models to account for differing length of follow-up and describe risk of receiving metastatic disease testing 7
Time to receipt of physical examinations and local recurrenceand metastatic disease testing by service type and age 9
Time from active treatment to surveillance:Breast cancer survivors Breast: 2 Physical Exams and 1 Mammogram 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0 6 12 18 24 30 36 Time in months from date of treatment with curative intent Aged < 50 Aged 50-64 Aged 65-74 Aged 75+10
Time from active treatment to surveillance:Colorectal cancer survivors Colorectal: 2 Physical Exams and 1 Complete Exam of the Colon 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0 6 12 18 24 30 36 Time in months from date of treatment with curative intent Aged < 50 Aged 50-64 Aged 65-74 Aged 75+11
Cox proportional hazards model:Metastatic disease testing within 18 monthsof treatment among breast cancer survivors 12
Cox proportional hazards model:Metastatic disease testing within 18 monthsof treatment among colorectal cancer survivors 13
Discussion Among geographically diverse cohorts of breast and colorectal cancer survivors, we found deviations in surveillance care relative to guideline recommendations. Overwhelming majority of breast and colorectal cancer survivors received the minimum recommended physical examinations. Majority of breast cancer survivors received recommended recurrence testing, whereas nearly 1/2 of colorectal cancer cohort failed to receive a complete examination of the colon within 18 months of treatment. Greater than 67% of survivors, particularly younger, received some type of metastatic disease testing within 18 months. 14
Limitations Study cohort members were limited to insured individuals who received their cancer care from 1 of 4 integrated health care delivery systems. Unable to ascertain whether care received was for surveillance versus other purposes. Grouping patients, with heterogeneity in prognoses, into general disease stages. 15
Future direction Compared with other phases of cancer control and prevention, surveillance care among cancer survivors appears to be understudied. Our findings highlight the wide variations in cancer surveillance among seemingly clinically similar patients and across different age groups. Need for research exploring whether observed variations are driven by patient preferences and reflect informed decision-making and how survivorship planning as outlined by the IOM can impact such variations. Given the survival advantage for patients aged < 65 years, it is important to consider the care trajectory and its implications among younger survivors. 16
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