Annual Meeting Proceedings Part 1 - American Society of Clinical ...

6004 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Effect of early palliative care on health care costs in patients with
metastatic NSCLC. Presenting Author: Joseph A. Greer, Massachusetts
General Hospital, Boston, MA
Background: Introducing palliative care soon after diagnosis for patients
with metastatic non-small cell lung cancer (NSCLC) leads to improvements
in quality of life, mood, end-of-life care, and possibly survival. We sought to
investigate whether early palliative care is also associated with health care
cost savings. Methods: This secondary analysis is based on a randomized
controlled trial of 151 patients with newly-diagnosed, metastatic NSCLC
presenting to an outpatient clinic at a tertiary cancer center between
6/2006 and 7/2009. Participants received either early palliative care
integrated with standard oncology care or standard oncology care alone. We
queried participants’ electronic health records as well as our institution’s
billing database to collect data on frequency and costs of outpatient clinic
visits, inpatient hospitalizations, chemotherapy administration, and hospice
services. The primary outcome was the difference in average resource
use costs during the final month of life between groups. Results: By
18-month follow up, 133 (88.1%) participants had died, and 125 (82.8%)
had available data for this analysis. Participants in the early palliative care
group had a mean cost savings of $2,282 (median�$2,432) per patient in
total health care expenditures during the final month of life compared to
the standard care group. The difference was primarily accounted for by
lower costs for inpatient visits (mean saving per patient�$3,110) and
chemotherapy administration (mean saving per patient�$640). Although
expenditures for outpatient clinic visits were similar between groups, the
costs for hospice services were greater for the early palliative care group
because of the longer lengths of stay in hospice care (mean cost per
patient�$1,125). Conclusions: Early palliative care for individuals diagnosed
with metastatic NSCLC not only improves multiple patient outcomes
but also may be associated with lower hospital resource use costs, primarily
through decreased inpatient visits and chemotherapy administration at the
end of life.
6006 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
A comparison of primary care providers’ and oncologists’ preferences for
different models of cancer survivorship care. Presenting Author: Winson Y.
Cheung, British Columbia Cancer Agency, Vancouver, BC, Canada
Background: There is increasing interest in developing more efficient and
effective strategies for coordinating and delivering cancer and non-cancer
related follow-up care to survivors. The objectives of this nationwide survey
were to describe and compare US physician preferences for different
cancer survivorship care models. Methods: The Survey of Physician Attitudes
Regarding the Care of Cancer Survivors (SPARCCS) was mailed to
PCPs and oncologists in order to evaluate their views regarding physician
responsibilities, knowledge levels about survivorship, and cancer follow-up
testing. Using weighted univariate and multivariate models, we analyzed
PCPs’ and oncologists’ preferences for different cancer survivorship care
models (PCP/shared vs. oncologist vs. non-physician provider) and examined
how physician attitudes towards and self-efficacy with their own skills
during breast and colorectal cancer follow-up affected these preferences.
Results: Of 3,434 physicians surveyed, 2,202 (64%) responded of whom
2,026 (59%) provided eligible outcomes for this study: 938 (46%) PCPs
and 1,088 (54%) oncologists. In unadjusted analyses, most PCPs (51%)
supported a PCP/shared care system whereas the majority of specialists
(59%) strongly endorsed an oncologist-based model (p�0.001). A number
of PCPs and oncologists (23% for both) preferred to involve non-physician
providers. A significant proportion of cancer specialists (87%) did not feel
that PCPs can take on the primary role for cancer follow-up. Many PCPs
believed that they have the skills to perform breast and colorectal cancer
follow-up (57%), detect recurrent cancers (74%), and offer psychosocial
support (50%), but only a minority (32%) were willing to assume exclusive
responsibility. In adjusted analyses, PCPs already involved with cancer
surveillance (43%) were more likely to prefer a PCP/shared care system
than an oncologist-based survivorship care model (OR 2.08, 95%CI
1.34-3.23, p�0.001). Conclusions: PCPs and oncologists have different
preferences for models of cancer survivorship care. Prior involvement with
cancer follow-up was one of the strongest predictors of PCPs’ willingness to
assume this responsibility.
Health Services Research
383s
6005 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Cancer patient acceptance, understanding, and willingness to pay for
pharmacogenetic testing (PGT). Presenting Author: Henrique Hon, Ontario
Cancer Institute, Princess Margaret Hospital, Toronto, ON, Canada
Background: PGT offers the potential to improve cancer therapy through the
use of specialized tests that can predict the level of efficacy and/or toxicity
of specific treatments in an individual. However, there is currently little
knowledge concerning cancer patient attitudes towards such testing in the
clinical setting. Methods: We interviewed a broad cross-section of 278
cancer patients (20% lung, 19% breast, 20% colorectal, 40% other) using
hypothetical time, efficacy, toxicity and willingness-to-pay trade-off PGT
scenarios. Results: 153 potentially curable patients and 125 incurable
patients received a separate series of trade-off scenarios. For curative
patients, 70% accepted chemo that had a 5% absolute improvement in
cure rate and �5% of severe toxicity. Of these, 99% wanted PGT where the
test identifies a subset of patients benefiting from chemo; the same
individuals were willing to pay a median $2,000 (range: $0-25,000) for
PGT and would accept a median wait time for PGT results of 21 days
(0-90). Patient preferences were insensitive to variation of fractions of
individuals carrying the genetics associated with lack of benefit. In the
incurable scenario, 90% of patients accepted palliative chemo with an
80% response rate and a severe side effect rate of 5%. Of these, 98%
wanted PGT, where there test identifies individuals at highest risk of severe
toxicity; the same individuals were willing to pay a median $1,000
($0-15,000) for PGT, and would accept PGT turnaround times of 14 days
(1-90). Patient preferences were insensitive to variation of fractions of
individuals carrying the genetics associated with severe toxicity. The
majority of patients (76% adjuvant; 87% metastatic) wanted to be involved
in decision making regarding PGT; however, one in five patients (20%
adjuvant; 22% metastatic) admitted that they lacked a basic understanding
of what PGT means and its clinical implications. Conclusions: Among
cancer patients willing to undergo chemo, almost all wanted PGT and were
willing to pay for it, waiting several weeks for results. While patients had a
strong desire to be involved in decision making for PGT, a considerable
proportion lacked the necessary knowledge to make informed choices.
6007 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Who gets a referral to oncologists and subsequent treatments for stages III
and IV non-small cell lung cancer (NSCLC)? Presenting Author: Bernardo
H.L. Goulart, Fred Hutchinson Cancer Research Center, Seattle, WA
Background: We identified the physicians initially involved in the management
of stages III and IV NSCLC, and explored associations of patient and
their initial physician factors with referrals to oncologists and subsequent
receipt of guideline-based therapies (GBTs) endorsed by the National
Comprehensive Cancer Network. Methods: Using a retrospective cohort
design, we identified patients with a new diagnosis of stages III and IV
NSCLC from 01/01/2000 to 12/31/2005 included in the Surveillance,
Epidemiology, and End Results-Medicare database. After collecting patient
sociodemographic, tumor, and treatment data, we linked Unique
Physician Identifier Numbers (UPINs) from Medicare claims to the American
Medical Association Masterfile database to identify the initial physicians
and subsequent referrals to cancer specialists, defined as surgeons,
radiation oncologists and oncologists. We used logistic regression to
explore associations between: 1) patient and initial physician independent
variables with referrals to oncologists; 2) referrals to different combinations
of cancer specialists with receipt of stage-specific GBTs, adjusted for
confounders. The follow-up period was 12 months or up to 12/31/2006.
Results: For 28,977 patients, mean age was 75 years, 53% were male,
83% were white, 51% had stage IV, 37% initially saw an internal medicine
doctor, 84% saw at least an oncologist, 31% saw all 3 types of cancer
specialists, and 44% received GBTs. Younger age, white race, stage IV,
higher income, lower co-morbidity index, initial physicians other than
family practice doctors, and referral to pulmonologists were associated with
higher likelihood of referral to oncologists (P�0.01 for all factors).
Compared to those who saw only an oncologist, those who saw only a
surgeon and/or a radiation specialist were less likely to receive GBTs
(OR�0.3; 95%CI�0.3-0.4). Among patients who had no referrals or who
saw specialties other than oncology, 14% received GBTs. Conclusions:
Seeing an oncologist is a critical step in the standard treatment of
advanced NSCLC. Yet, race, income, and the type of initial physician may
constitute barriers of access to oncologists, which can result in substandard
care.
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