Two Studies Highlight Communication Challenges Facing Medical Oncology


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Ankit J. Kansagra, MD

Christine M. Bestvina, MD

Robert D. Siegel, MD

In one study presented at ASCO’s second annual Quality Care Symposium in San Diego, patients receiving chemotherapy with palliative care intent were at high risk of side-effect–related hospitalization, which defeats the clinical purpose and adds preventable costs to health care.1

“There is an increasing use of palliative chemotherapy. If risks of toxicity of that chemotherapy are underappreciated or misunderstood, the goals of palliative care are undermined,” said lead author Ankit J. Kansagra, MD, a hematology/oncology fellow at Tufts University School of Medicine, Boston.

Nested Case-Control Study

Dr. Kansagra and his associates conducted a nested case-control study of adult cancer patients at North Shore Medical Center in Salem, Massachusetts, who received chemotherapy between January 2003 and December 2011. Of the 6,850 adult patients who received chemotherapy, 2,559 (37.3%) had the therapy delivered with palliative intent. Of that group, 230 patients (9%) required treatment-associated hospitalization; 199 of those cases were included in the research.

The study also included two matched controls for each case, amounting to 398 patients in the control group who underwent the same lines of therapy but did not need to be hospitalized. The most common cancers among patients who required hospitalization were gastrointestinal (36%) and lung (32%), followed by breast cancer (14%). The chemotherapies were also broadly distributed, with platinum-based regimens being the most commonly used (50%), followed by taxanes (27%), fluorouracil (25%), and camptothecins (19%).

Communication Distortions

Panel discussant for the session, Robert D. Siegel, MD, of Hartford Hospital in Hartford, Connecticut, noted, “The administration of palliative chemotherapy cannot and should not happen in a void.” He stressed that there is evidence that the intent of palliative chemotherapy is often misconstrued by patients. “However, in this setting there is often a miscommunication in which the patient believes that the palliative treatment is also being given to cure the cancer,” he stressed.

Dr. Siegel added, “There are clearly some communication distortions at the time of diagnosis leading to the determination of what therapy to deliver and when to deliver it. Identifying the issues underlying this miscommunication would result in better informed patients capable of better assessing the risks and benefits of palliative chemotherapy. This might be the most effective method of diminishing chemotherapy-related hospitalizations. Prior studies have suggested that early introduction of  palliative care discussions can lessen patient misconceptions regarding the intent of care.”

Dr. Kansagra concluded, “We’ve found that patients receiving palliative chemotherapy are at increased risk of hospitalization. Identifying predictors of severe toxicity may help caregivers and patients make informed decisions about their therapeutic options.”

Study Two: Drug Costs Affect Patient Decisions

As a general rule, most insurance plans cover cancer drugs used by Medicare beneficiaries. However, according to results of a cross-sectional survey presented at the ASCO Quality Care Symposium, many of today’s high-cost cancer drugs impose out-of-pocket costs on cancer patients that affect their treatment decisions.2

Lead author of this second study Christine M. Bestvina, MD, a resident at Duke University Medical Center in Durham, North Carolina, said, “Nonadherence to medications and chemotherapy because of high copays is common. Those who had previously discussed out-of-pocket costs of cancer care with their oncologists were more likely to report medication non-adherence. This study raises important questions for oncologists regarding shared-decision conversations, and why they objectively could be important. Dr. Bestvina asked the audience, “Can we use discussions of costs in the clinic as potentially a red flag for medication nonadherence when that patient leaves the office?”

The survey included 300 insured respondents diagnosed with solid tumors. The most common malignancy was colorectal; 78% of the group had advanced-stage cancer. The median income of the survey group was about $60,000 per year; 52 (17%) reported a state of “high” or “overwhelming” financial distress. A total of 56 patients (19%) had talked to their oncologists about out-of-pocket costs, and 52% of the patients expressed in the survey a desire to have cost discussions with their physicians.

Nonadherence parameters included skipping doses, taking less medication than prescribed in order to make the prescription last longer, or simply not filling the prescription because of cost. A total of 80 patients reported nonadherence to their cancer medications. Of those patients who skipped their medications, 7% skipped chemotherapy doses. Of those who took less than prescribed, 15% did so with a chemotherapy drug. Ten patients reported not filling a chemotherapy prescription because of cost.

Study Limitation

Dr. Bestvina commented that the trial was limited by the self-reporting of nonadherence, as well as by the lack of information on temporality. “A better understanding of the timeline, content, and quality of the doctor-patient discussion about the costs of cancer treatments is important,” said Dr. Bestvina.

Given the current school of thought that “more information and shared decision-making leads to better outcomes for patients,” it is noteworthy that the connection between more information about out-of-pocket costs is associated with treatment nonadherence, a poorer outcome. Dr. Bestvina said that her study indicated that more work is needed in this difficult-to-navigate clinical scenario. ■

Disclosure: Drs. Kansagra, Siegel, and Bestvina reported no potential conflicts of interest.

References

1. Kansagra AJ, Brooks G, Gao JH, et al: Risk factors for the development of chemotherapy-related hospitalization (CRH) in patients treated with palliative intent: Results of a 9-year nested case control study. 2013 Quality Care Symposium. Abstract 3. Presented November 1, 2013.

2. Bestvina CM, Zullig LL, Rushing C, et al: Patient-oncologist cost communication, financial distress, and medication adherence. 2013 Quality Care Symposium. Abstract 2. Presented November 2, 2013.



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