The Asco Post

Access to Care: Who Gets Referred to a Medical Oncologist and/or Another Cancer Specialist and Who Receives Treatment for Advanced Cancer? 

By Charlotte Bath
May 1, 2013, Volume 4, Issue 7

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What factors determine who is referred to a medical oncologist and receives treatment for advanced cancers? Several articles in the Journal of Oncology Practice suggest that factors influencing referral and treatment go beyond the patient’s medical condition and preference and include such details as where patients live and receive care, where oncologists practice, and whether guidelines are followed. Racial and income disparities still present barriers for some patients.

Advanced Age and Stage

Patients who are older, have advanced-stage disease, or have cancers that are either difficult to treat or for which active surveillance may be recommended are less likely to receive treatment, according to a study based on data from 113,885 patient cases with invasive cancer diagnoses.1 “Surgery and chemotherapy were the recommended treatment modalities that were most commonly refused,” reported Marcia M. Ward, PhD, of the University of Iowa, Iowa City, and colleagues from Beth Israel Deaconess Medical Center, Boston; Memorial Sloan-Kettering Cancer Center, New York; and the American Society of Clinical Oncology, Alexandria, Virginia.

Patients with lung/bronchial cancer, low-grade non-Hodgkin lymphoma, and prostate cancer were significantly more likely to not be treated. “In contrast, patients with breast, cervical, colon, melanoma, and rectal cancers were significantly less likely to not be treated,” Dr. Ward and colleagues reported.

“Not receiving treatment was significantly more common in rural residents than in urban residents,” the investigators added. “Not receiving treatment increased significantly with age and cancer stage. In fact, patients with stage II or III disease were twice as likely to not receive treatment as those with early-stage disease (stage I), and dramatically, stage IV cancers were six times more likely to not be treated.”

Most patients with invasive cancer received treatment, but 12.3% of cases had documentation that patients did not receive a first course of treatment. This nontreatment rate, based on data from the Iowa Cancer Registry, is 48% higher than the rate reported by the National Cancer Data Base (NCDB), which compiles data from cancer program registries accredited by the Commission on Cancer (COC), “but lacks data from the 30% of patient cases that are not represented by COC-accredited cancer programs,” the study authors noted. “This difference in rates suggests that nontreatment is less common in patients seen in COC-accredited cancer programs and that nontreatment for cancer is more common than the NCDB data indicate.” Nontreatment was also less common for patients who saw an oncologist, radiation therapist, or surgeon.

The study grew out of the larger ASCO Study of Geographic Access to Oncology Care, which was designed to determine if there are gaps in the geographic distribution of physicians and patient access to treatment sites that may contribute to disparities in cancer care. Findings from that study are expected later this year.

Where Patients Live and Oncologists Practice

Where patients live can increase or decrease the chances that they will receive chemotherapy following surgery for stage III colon cancer, as recommended by National Comprehensive Cancer Network (NCCN) guidelines. A study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database identified 9,262 patients who were aged ≥ 66 years and underwent colectomy for stage III colon cancer diagnosed from 2000 to 2005. Chun Chieh Lin, PhD, MBA, and Katherine S. Virgo, PhD, MBA, of the American Cancer Society and Emory University, Atlanta, found that the likelihood of initiating chemotherapy following colon resection surgery was approximately 1.5 times higher for patients residing in a hospital service area with one or more medical oncologists than with no medical oncologists.2

In addition, Drs. Lin and Virgo reported that the following factors were associated with a decreased likelihood of initiating chemotherapy within 3 months after colectomy: age > 70 years (P < .001), African American ethnicity (P < .01), current unmarried status or unknown marital status (P< .001), comorbidity score ≥ 1 (P < .001), dual eligibility for Medicare and Medicaid (P < .001), and more recent diagnosis (ie, 2005; P < .05).

Overall, only 60.19% of patients in the study initiated chemotherapy with 3 months of surgery, which the authors noted, is “consistent with previous studies.” Previous studies have also shown that older patients are less likely to be referred to medical oncologists for treatment and to receive chemotherapy, even though the NCCN guidelines recommend colectomy followed by 6 months of adjuvant chemotherapy for patients with stage III colon cancer, and chemotherapy after colon resection has been shown to improve survival in younger and older patients.

Racial and Income Disparities Persist

Patients with stage III/IV non–small cell lung cancer (NSCLC) who were older, black, lived in lower-income areas, had higher comorbidities, and were initially seen by a family practice physician vs a general internist, were less likely to be referred to medical oncologists, according to a study of 28,977 patients in the SEER-Medicare database.3

Patient data was linked to data about the patients’ physicians in the American Medical Association Masterfile database to identify physician factors associated with referrals to cancer specialists (medical oncologists, radiation oncologists, and surgeons) and how seeing these cancer specialists correlated with delivery of guideline-based therapies, as defined by current versions of the NCCN practice guidelines. The results were reported by Bernardo H.L. Goulart, MD, MS, and colleagues from Fred Hutchinson Cancer Research Center and University of Washington, Seattle; Genentech, San Francisco; and Q.D. Research, Granite Bay, California.

“Seeing the three types of cancer specialists predicted higher likelihood of [guideline-based therapies] (stage IIIA: odds ratio [OR] = 20.6; P < .001; IIIB: OR = 77.2; P < .001; and IV: OR = 1.2;
P = .011), compared with seeing a medical oncologist only. Use of [guideline-based therapies] increased over the study period (42% to 48% from 2000 to 2005; P < .001),” results showed.

“Within 6 months from diagnosis, 24,462 patients (84%) saw at least a medical oncologist, and 9,053 patients (31%) saw all cancer specialists (medical oncologists, radiation oncologists, and thoracic or general surgeons),” the researchers reported. “Although patients with stages IIIA and IIIB were more likely to see all types of cancer specialists than stage IV patients (41% and 32% vs28%, P < .001), patients with stages IIIA and IIIB were less likely to receive care consistent with guidelines than stage IV patients (45% and 30% vs54%, P < .001),” the authors noted.

Consistent with previous observational studies, the current study found that patients who were older, black, or lived in lower-income areas had a lower likelihood of referrals to medical oncologists, as did patients seen initially by family practice physicians. “These findings indicate that sociodemographic characteristics still represent access barriers to specialty care for NSCLC and that some general practitioners are not fully aware of the role of chemotherapy for stages III and IV NSCLC,” the authors asserted. “Health care systems need to promote efforts that increase access to specialty care so that only medical factors and patient preferences determine the receipt of cancer therapy modalities.”

Dr. Goulart and coauthors did note that patients “diagnosed in more recent years were more likely to see medical oncologists and to receive recommended therapies. This increasing trend in adoption of evidence-based practices suggests improvements in supportive care, lower surgical morbidity, and increased dissemination of guideline recommendations through scientific events and multimedia tools, including Web-enabled electronic health records.”

Missed Opportunities for End-of-life Care?

An unscheduled hospitalization for a patient with advanced cancer “strongly predicts survival of fewer than 6 months,” according to survey data, and may represent a missed opportunity to move patients to end-of-life care. This conclusion was based on analysis of data collected on hospital admissions, interventions, and survival, in two separate surveys conducted at the University of Wisconsin Hospital in Madison inpatient oncology service.4 The results were reported by Gabrielle B. Rocque, MD, and colleagues from the University of Wisconsin, Madison; Park Nicollet Methodist Hospital, St. Louis Park, Minnesota; and Bay State Medical Center and Tufts University School of Medicine, Springfield, Massachusetts.

A 2000 survey included 191 admissions of 151 unique patients, and a 2010 survey assessed 149 admissions of 119 patients. The most common diagnoses were for lung, gastrointestinal, and breast cancers. Most patients were admitted for uncontrolled symptoms.

“The median survival of patients after discharge was 4.7 months in 2000 and 3.4 months in 2010. Despite poor survival in this patient population, hospice was recommended in only 23% and 24% of patients in 2000 and 2010, respectively. Seventy percent of patients were discharged home without additional services,” Dr. Rocque and colleagues stated.

“Although the prognosis for patients with metastatic cancer varies widely based on the primary site, patients who are hospitalized have a poor prognosis regardless of cancer type,” the authors noted. “Given the overall poor survival, any patient with metastatic cancer with an unscheduled hospitalization could be considered hospice eligible and appropriate for end-of-life planning, including discussion of advanced directives. Palliative care consultation would be a potential intervention to better address end-of-life care for these patients.” ■

Disclosure:Dr. Carolina M. Reyes has had an employment or leadership position with Genentech and stock ownership in Roche. Dr. Sacha Satram-Hoang has served in a consultant or advisory role for Genentech. Dr. Bernardo H.L. Goulart, Ms. Catherine R. Fedorenko, Mr. David G. Mummy, Ms. Lisel M. Koepl, and Dr. Scott D. Ramsey have received research funding from Genentech (all reference 3). The authors of the other studies discussed in this article reported no potential conflicts of interest.

References

1. Ward MM, Ullrich F, Matthews K, et al: Who does not receive treatment for cancer? J Oncol Pract 9:20-26, 2013.

2. Lin CC, Virgo KS: Association between the availability of medical oncologists and initiation of chemotherapy for patients with stage III colon cancer. J Oncol Pract 9:27-33, 2013.

3. Goulart BHL, Reyes CM, Fedorenko CR, et al: Referral and treatment patterns among patients with stages III and IV non–small-cell lung cancer.  J Oncol Pract 9:42-50, 2013.

4. Rocque GB, Barnett AE, Illig LC, et al: Inpatient hospitalization of oncology patients: Are we missing an opportunity for end-of-life care? J Oncol Pract 9:51-54, 2013.

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