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

6012 Clinical Science Symposium, Sun, 8:00 AM-9:30 AM
Racial differences in the impact of financial hardship on the intensity of
end-of-life cancer care. Presenting Author: Reginald D. Tucker-Seeley,
Dana-Farber Cancer Institute, Boston, MA
Background: Research suggests that Black cancer patients have higher
end-of-life (EOL) medical costs than White patients; and that Black,
compared with White, families are more likely to use all or most of their
savings to pay for EOL care. Although Black cancer patients receive more
intense EOL care than Whites, research has yet to determine the effect of
financial hardship on receipt of intensive EOL care, and whether the effect
varies by the patient’s race. Methods: Coping with Cancer (CwC) is a
longitudinal, multi-site cohort study of advanced cancer patients and their
informal caregivers recruited from September 2002-February 2008. CwC
was designed to investigate Black/White differences in EOL care. The
purpose of this analysis was to determine the association between baseline
financial hardship and receipt of intensive EOL care in the last week of life
(CwC deceased cohort N�342), and to identify racial differences in this
association. Financial hardship was defined as whether the household had
to use all or most of their savings due to the family member’s illness
(response �yes/no). Intensive EOL care was defined as the receipt of
ventilation or resuscitation in the last week of life assessed by medical
record review and patient’s caregiver. Results: Patients reporting financial
hardship had higher odds of receiving intensive EOL care (OR � 2.83, CI:
1.33, 6.05). After adjusting for socio-demographic characteristics the
significant association remained (OR � 2.55, CI: 1.13, 5.81). Racestratified
fully adjusted models revealed no statistically significant association
between financial hardship and intensive EOL care for Whites;
however, for Blacks, those reporting financial hardship had over five times
higher odds of receiving intensive EOL care (OR � 5.21, CI: 1.51, 17.99)
compared to those not reporting financial hardship. Conclusions: Financial
hardship was associated with greater likelihood of receiving intensive EOL
care. The intensity of EOL care received by White patients was insensitive
to financial hardship; in contrast Black patients reporting depletion of life
savings for cancer care were much more likely to die receiving intensive
EOL care than their non-financially strained counterparts.
6014 Poster Discussion Session (Board #2), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Adjuvant chemotherapy (AC) initiation and early discontinuation in elderly
patients (EPs) with stage III colon cancer (CC). Presenting Author: Jenny J.
Ko, British Columbia Cancer Agency, Vancouver, BC, Canada
Background: Research suggests that EPs with cancer are commonly
undertreated, but the precise reasons for this observation are unclear. Our
aims were to 1) evaluate the impact of advanced age on AC use (none vs
capecitabine vs FOLFOX) for stage III CC, 2) determine the specific reasons
for selecting and discontinuing a particular regimen, and 3) examine if the
effect of AC on outcomes is modified by age. Methods: Patients diagnosed
with stage III CC from 2006 to 2008 and referred to any 1 of 5 cancer
centers in British Columbia, Canada were identified. Descriptive statistics
were used to summarize treatment patterns in young patients (YPs) aged
�70 vs EPs aged �/�70 years. Logistic regression was used to evaluate
the association between AC and cancer-specific survival (CSS) in YPs and
EPs. Results: We identified 810 patients: 51% men, 52% YPs and 48%
EPs, and 74% received AC in the entire cohort. When compared to YPs,
EPs had worse ECOG and more comorbidities (both p�0.01). EPs were less
likely than YPs to receive AC (57 vs 91%, p�0.01). Frequent reasons for no
treatment included age, comorbidities and perceived minimal benefit from
AC. Among those treated with AC, EPs were less likely to receive FOLFOX
(32 vs 74%, p�0.01) in favor of capecitabine due to patient preference,
age and comorbidities. Once started on AC, EPs had similar rates of early
treatment discontinuation as YPs (70 vs 62%, p�0.08). Reasons for early
discontinuation were comparable between EPs and YPs (Table). Receipt of
either FOLFOX or capecitabine was correlated with improved CSS, compared
to surgery alone. Age did not modify CSS, irrespective of AC choice
(interaction p for capecitabine and age�0.26; interaction p for FOLFOX
and age�0.40). Conclusions: EPs with stage III CC frequently received
either no adjuvant treatment or capecitabine monotherapy due to advanced
age and comorbidities. The treatment effect of AC on CSS is similar across
age groups, with comparable side effects and rates of discontinuation
between EPs and YPs. AC should not be withheld from CC patients based
on advanced age alone.
Reasons for early discontinuation
Side effects p Progressive disease p Patient choice p
YPs 59% 0.99 21% 0.39 6% 0.27
EPs 58% 16% 10%
Health Services Research
385s
6013 Poster Discussion Session (Board #1), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Toxicity of chemotherapy dosing using actual body weight in obese versus
normal-weight patients: A systematic review and meta-analysis. Presenting
Author: Kathryn Cunningham Hourdequin, Dartmouth Hitchcock Medical
Center, Lebanon, NH
Background: Because weight-based chemotherapy calculations can be very
large in obese patients, oncologists often empirically reduce doses due to
fear of excess toxicity. The resulting underdosing may negatively impact
survival. We performed a systematic review and meta-analysis to determine
whether, among adults receiving chemotherapy dosed by actual body
weight (ABW), obese patients experience differing toxicity or survival
compared to normal-weight patients. Methods: We searched MEDLINE,
Cochrane Library, Web of Science, and ClinicalTrials.gov through October
2011 and reviewed reference lists. We included studies that compared
outcomes of obese versus normal-weight adults receiving chemotherapy
dosed according to ABW (�/- 5% variability). Studies followed subjects for
at least one cycle of chemotherapy and reported at least one pre-specified
outcome. Two authors independently abstracted data from eligible studies.
We used random effects models to pool odds ratios (OR) for hematologic
and non-hematologic toxicities. We summarized survival qualitatively.
Results: Of 3,921 studies, five met inclusion criteria, for a total of 6,877
subjects. Based on three studies, Grade 3/4 hematologic toxicity occurred
less often in obese patients than normal-weight patients (OR 0.68, 95% CI
0.51-0.89, I2�29%). A fourth study comparing leukocyte nadirs had
variable results depending on the regimen, dosing, and patient comorbidities.
Based on two studies, Grade 3/4 non-hematologic toxicity
occurred less often in obese patients than normal-weight patients (OR
0.74, 95% CI 0.63-0.87, I2�0%). A third study found rates of infection
did not significantly differ. Three of four studies reported reduced overall
survival in obese patients (statistical significance not reported). Conclusions:
Contrary to common belief, obese patients receiving chemotherapy based
on ABW appear to have lower rates of both hematologic and nonhematologic
toxicities compared to normal-weight patients. These results
do not support the practice of empiric dose reduction in obese patients.
Further research should explore etiologies for the reduced survival in this
group.
6015 Poster Discussion Session (Board #3), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Comorbidity, chemotherapy toxicity, and outcomes among older women
receiving adjuvant chemotherapy for breast cancer (BC). Presenting Author:
Heidi D. Klepin, Wake Forest School of Medicine, Winston-Salem, NC
Background: Comorbidity increases with age. We evaluated how comorbidity
was associated with toxicity and clinical outcomes among older women
with BC who received adjuvant chemotherapy. Methods: Cancer and
Leukemia Group B (CALGB 49907) enrolled 633 women �65 years with
early stage BC and randomized them to standard adjuvant chemotherapy
(AC or CMF) or capecitabine (N Eng J Med 360:2055, 2009). 329 women
on the Quality of Life companion study completed a pre-treatment health
survey (Older American Resources and Services Questionnaire, physical
health subscale). The survey evaluates 14 conditions and the degree to
which each interferes with daily activities (rated from 1 “not at all” to 3 “a
great deal”). Comorbidity was analyzed as follows: 1) total number 2)
comorbidity burden score (summed conditions multiplied by interference
rating); and 3) individual diseases. Primary outcomes were: 1) grade 3-5
toxicity (incident and cumulative); 2) time to relapse (TTR), and 3) overall
survival (OS). Contingency table methods were used to evaluate the
association between comorbidity and toxicity. Cox proportional hazards
models were used to evaluate TTR and survival outcomes. Results: Among
329 women [median age 71 years (range 65-89), 86% white, 98% ECOG
performance score 0-1, 75% stage 1-2] the median number of comorbidities
was 2 (0-10), median comorbidity burden score was 3 (0-25), and
most common conditions were arthritis (58%) and hypertension (54%).
Few patients had diabetes (17%), heart disease (16%), and pulmonary
disease (9%). No comorbidity measure was associated with toxicity or TTR.
With a median follow-up of 5.4 years, increasing comorbidity was associated
with shorter OS. For each additional comorbid condition the hazard of
death increased by 18% (HR 1.18 [95% CI; 1.06-1.33]) after adjusting for
age, tumor size, treatment, node status and receptor status. Comorbidity
burden score was similarly associated with OS (HR 1.08 [95% CI;
1.03-1.14]), while no specific condition was independently associated.
Conclusions: Among older women with good functional status, comorbidity
was not associated with toxicity or BC relapse. However, comorbidity
burden was associated with shorter OS.
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