Cancer Survivors Lag in Care for Comorbid Conditions

CHICAGO – The quality of care that older cancer survivors receive for comorbid conditions such as diabetes and heart failure varies by tumor type, according to a retrospective, cross-sectional analysis of database records for more than 25,000 people.

Colorectal cancer survivors fared the worst of three tumor cohorts studied. Compared with a control group of cancer-free patients, they were more likely to receive acute and chronic care that was subpar on a variety of measures, Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors fared best, receiving equivalent acute and better chronic care than did cancer-free controls. Prostate cancer survivors came out somewhere in the middle, receiving worse acute care but better chronic care.

The study "does not explain why care was or was not provided," Dr. Snyder said, listing its limitations. She hopes to explore why survivor care varies by tumor type as well as possible relationships with cost, she added.

"The issue of comorbid-condition care in cancer survivors has been understudied. As our treatments improve and survivors live longer with a history of a cancer diagnosis, quality care for comorbid conditions takes on greater importance," said Dr. Snyder of Johns Hopkins University in Baltimore.

Cancer survivors’ health care needs include surveillance for recurrence and monitoring for the physical and psychosocial long-term and late effects of the disease and its treatment, she said. Their needs also include general primary and preventive care, and often care for comorbid conditions.

This study used data from the SEER (Surveillance, Epidemiology and End Results)–Medicare database, a cancer registry linked with Medicare claims data. The nation’s 17 SEER registries cover a representative sample of more than one-quarter of the U.S. population. Medicare claims data on noncancer controls who live in SEER regions were used for comparison.

The study population was diagnosed with locoregional breast, prostate, or colorectal cancer in 2004. They were at least 66 years old and were enrolled in fee-for-service Medicare during the study period. They had survived at least 3 years from diagnosis, and had no evidence of ongoing cancer treatment.

The 8,661 cancer survivors in the study were "frequency matched" with 17,322 cancer-free controls. Slightly more than half of the cancer group (4,559) had survived prostate cancer; 2,231 had survived colorectal cancer; and 1,871 survived breast cancer. The study period covered years 2 and 3 from day of diagnosis.

The final sample had a mean age of approximately 75 years; nearly two-thirds were men, and 85% were white. More than 88% in both case and control groups lived in an urban area.

There were 9 quality indicators for care of chronic conditions, and 19 for care of acute conditions. To calculate the percentage of survivors receiving appropriate care, investigators divided the number of cases and controls who received appropriate care by the number eligible for each indicator.

A summary analysis showed that among colorectal cancer survivors, there were four indicators of worse chronic care (chronic obstructive pulmonary disease visits, lipid monitoring after angina, diabetes eye exams, and diabetes monitoring), and three indicators of worse acute care (visits after acute MI and heart failure hospitalizations, and cholecystectomy), compared with controls.

Prostate cancer survivors had three indicators of worse acute care (ECG after heart failure, chest film after heart failure, and cholecystectomy), but two indicators of better chronic care (COPD and diabetes visits).

The breast cancer survivors did better on COPD and diabetes visits.

Quality indicators for the care of chronic conditions included the following:

• Visit frequency of 6 months for chronic stable angina, heart failure, COPD, and diabetes.

• Visit frequency of 12 months for transient ischemic attack (TIA).

• Cholesterol test every 6 months for patients with hypercholesterolemia who were hospitalized with acute MI.

• Lipid profile up to 1 year after initial diagnosis of angina.

• Yearly eye exam for diabetes patients.

• Glycosylated hemoglobin and fructosamine every 6 months for diabetes patients.

Quality indicators for the care of acute conditions included the following:

• Visits up to 4 weeks after discharge after hospitalization for acute MI, unstable angina, heart failure, cerebrovascular accident, TIA, diabetes, malignant or otherwise severe hypertension, or gastrointestinal bleed.

• Visits up to 2 weeks after discharge for patients hospitalized with depression.

• Visits up to 1 week after diagnosis of unstable angina (visit or hospitalization).

• ECG during emergency department visit for unstable angina.

• ECG up to 3 months after initial diagnosis of heart failure.

• ECG up 2 days of initial diagnosis of TIA.

• Chest radiograph up to 3 months after initial diagnosis of heart failure.

• Carotid imaging up to 2 weeks after initial diagnosis for patients hospitalized with carotid artery stroke.

• Carotid endarterectomy up to 2 months after carotid imaging for cerebrovascular accident patients with eventual carotid endarterectomy.

• Carotid endarterectomy up to 2 months after carotid imaging for TIA patients with eventual carotid endarterectomy.

• Cholecystectomy for patients with cholelithiasis plus cholecystitis, cholangitis, or gallstone pancreatitis.

• Arthroplasty or internal fixation of hip during hospital stay for hip fracture.

Among the study’s strengths, Dr. Snyder said that it examined the initial transition from acute cancer treatment to survivorship, an important time to ensure that survivors do not get lost in transition.

Discussant Lynne I. Wagner, Ph.D., of Northwestern University in Chicago said that this represented a novel contribution to the evidence base in survivorship care. "The comorbidity issues are extremely important. This is probably the tip of the iceberg in terms of what’s going on," she said.

The study was funded by the National Cancer Institute. Neither Dr. Snyder nor Dr. Wagner disclosed relevant relationships.

CHICAGO – The quality of care that older cancer survivors receive for comorbid conditions such as diabetes and heart failure varies by tumor type, according to a retrospective, cross-sectional analysis of database records for more than 25,000 people.

Colorectal cancer survivors fared the worst of three tumor cohorts studied. Compared with a control group of cancer-free patients, they were more likely to receive acute and chronic care that was subpar on a variety of measures, Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors fared best, receiving equivalent acute and better chronic care than did cancer-free controls. Prostate cancer survivors came out somewhere in the middle, receiving worse acute care but better chronic care.

The study "does not explain why care was or was not provided," Dr. Snyder said, listing its limitations. She hopes to explore why survivor care varies by tumor type as well as possible relationships with cost, she added.

"The issue of comorbid-condition care in cancer survivors has been understudied. As our treatments improve and survivors live longer with a history of a cancer diagnosis, quality care for comorbid conditions takes on greater importance," said Dr. Snyder of Johns Hopkins University in Baltimore.

Cancer survivors’ health care needs include surveillance for recurrence and monitoring for the physical and psychosocial long-term and late effects of the disease and its treatment, she said. Their needs also include general primary and preventive care, and often care for comorbid conditions.

This study used data from the SEER (Surveillance, Epidemiology and End Results)–Medicare database, a cancer registry linked with Medicare claims data. The nation’s 17 SEER registries cover a representative sample of more than one-quarter of the U.S. population. Medicare claims data on noncancer controls who live in SEER regions were used for comparison.

The study population was diagnosed with locoregional breast, prostate, or colorectal cancer in 2004. They were at least 66 years old and were enrolled in fee-for-service Medicare during the study period. They had survived at least 3 years from diagnosis, and had no evidence of ongoing cancer treatment.

The 8,661 cancer survivors in the study were "frequency matched" with 17,322 cancer-free controls. Slightly more than half of the cancer group (4,559) had survived prostate cancer; 2,231 had survived colorectal cancer; and 1,871 survived breast cancer. The study period covered years 2 and 3 from day of diagnosis.

The final sample had a mean age of approximately 75 years; nearly two-thirds were men, and 85% were white. More than 88% in both case and control groups lived in an urban area.

There were 9 quality indicators for care of chronic conditions, and 19 for care of acute conditions. To calculate the percentage of survivors receiving appropriate care, investigators divided the number of cases and controls who received appropriate care by the number eligible for each indicator.

A summary analysis showed that among colorectal cancer survivors, there were four indicators of worse chronic care (chronic obstructive pulmonary disease visits, lipid monitoring after angina, diabetes eye exams, and diabetes monitoring), and three indicators of worse acute care (visits after acute MI and heart failure hospitalizations, and cholecystectomy), compared with controls.

Prostate cancer survivors had three indicators of worse acute care (ECG after heart failure, chest film after heart failure, and cholecystectomy), but two indicators of better chronic care (COPD and diabetes visits).

The breast cancer survivors did better on COPD and diabetes visits.

Quality indicators for the care of chronic conditions included the following:

• Visit frequency of 6 months for chronic stable angina, heart failure, COPD, and diabetes.

• Visit frequency of 12 months for transient ischemic attack (TIA).

• Cholesterol test every 6 months for patients with hypercholesterolemia who were hospitalized with acute MI.

• Lipid profile up to 1 year after initial diagnosis of angina.

• Yearly eye exam for diabetes patients.

• Glycosylated hemoglobin and fructosamine every 6 months for diabetes patients.

Quality indicators for the care of acute conditions included the following:

• Visits up to 4 weeks after discharge after hospitalization for acute MI, unstable angina, heart failure, cerebrovascular accident, TIA, diabetes, malignant or otherwise severe hypertension, or gastrointestinal bleed.

• Visits up to 2 weeks after discharge for patients hospitalized with depression.

• Visits up to 1 week after diagnosis of unstable angina (visit or hospitalization).

• ECG during emergency department visit for unstable angina.

• ECG up to 3 months after initial diagnosis of heart failure.

• ECG up 2 days of initial diagnosis of TIA.

• Chest radiograph up to 3 months after initial diagnosis of heart failure.

• Carotid imaging up to 2 weeks after initial diagnosis for patients hospitalized with carotid artery stroke.

• Carotid endarterectomy up to 2 months after carotid imaging for cerebrovascular accident patients with eventual carotid endarterectomy.

• Carotid endarterectomy up to 2 months after carotid imaging for TIA patients with eventual carotid endarterectomy.

• Cholecystectomy for patients with cholelithiasis plus cholecystitis, cholangitis, or gallstone pancreatitis.

• Arthroplasty or internal fixation of hip during hospital stay for hip fracture.

Among the study’s strengths, Dr. Snyder said that it examined the initial transition from acute cancer treatment to survivorship, an important time to ensure that survivors do not get lost in transition.

Discussant Lynne I. Wagner, Ph.D., of Northwestern University in Chicago said that this represented a novel contribution to the evidence base in survivorship care. "The comorbidity issues are extremely important. This is probably the tip of the iceberg in terms of what’s going on," she said.

The study was funded by the National Cancer Institute. Neither Dr. Snyder nor Dr. Wagner disclosed relevant relationships.

CHICAGO – The quality of care that older cancer survivors receive for comorbid conditions such as diabetes and heart failure varies by tumor type, according to a retrospective, cross-sectional analysis of database records for more than 25,000 people.

Colorectal cancer survivors fared the worst of three tumor cohorts studied. Compared with a control group of cancer-free patients, they were more likely to receive acute and chronic care that was subpar on a variety of measures, Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors fared best, receiving equivalent acute and better chronic care than did cancer-free controls. Prostate cancer survivors came out somewhere in the middle, receiving worse acute care but better chronic care.

The study "does not explain why care was or was not provided," Dr. Snyder said, listing its limitations. She hopes to explore why survivor care varies by tumor type as well as possible relationships with cost, she added.

"The issue of comorbid-condition care in cancer survivors has been understudied. As our treatments improve and survivors live longer with a history of a cancer diagnosis, quality care for comorbid conditions takes on greater importance," said Dr. Snyder of Johns Hopkins University in Baltimore.

Cancer survivors’ health care needs include surveillance for recurrence and monitoring for the physical and psychosocial long-term and late effects of the disease and its treatment, she said. Their needs also include general primary and preventive care, and often care for comorbid conditions.

This study used data from the SEER (Surveillance, Epidemiology and End Results)–Medicare database, a cancer registry linked with Medicare claims data. The nation’s 17 SEER registries cover a representative sample of more than one-quarter of the U.S. population. Medicare claims data on noncancer controls who live in SEER regions were used for comparison.

The study population was diagnosed with locoregional breast, prostate, or colorectal cancer in 2004. They were at least 66 years old and were enrolled in fee-for-service Medicare during the study period. They had survived at least 3 years from diagnosis, and had no evidence of ongoing cancer treatment.

The 8,661 cancer survivors in the study were "frequency matched" with 17,322 cancer-free controls. Slightly more than half of the cancer group (4,559) had survived prostate cancer; 2,231 had survived colorectal cancer; and 1,871 survived breast cancer. The study period covered years 2 and 3 from day of diagnosis.

The final sample had a mean age of approximately 75 years; nearly two-thirds were men, and 85% were white. More than 88% in both case and control groups lived in an urban area.

There were 9 quality indicators for care of chronic conditions, and 19 for care of acute conditions. To calculate the percentage of survivors receiving appropriate care, investigators divided the number of cases and controls who received appropriate care by the number eligible for each indicator.

A summary analysis showed that among colorectal cancer survivors, there were four indicators of worse chronic care (chronic obstructive pulmonary disease visits, lipid monitoring after angina, diabetes eye exams, and diabetes monitoring), and three indicators of worse acute care (visits after acute MI and heart failure hospitalizations, and cholecystectomy), compared with controls.

Prostate cancer survivors had three indicators of worse acute care (ECG after heart failure, chest film after heart failure, and cholecystectomy), but two indicators of better chronic care (COPD and diabetes visits).

The breast cancer survivors did better on COPD and diabetes visits.

Quality indicators for the care of chronic conditions included the following:

• Visit frequency of 6 months for chronic stable angina, heart failure, COPD, and diabetes.

• Visit frequency of 12 months for transient ischemic attack (TIA).

• Cholesterol test every 6 months for patients with hypercholesterolemia who were hospitalized with acute MI.

• Lipid profile up to 1 year after initial diagnosis of angina.

• Yearly eye exam for diabetes patients.

• Glycosylated hemoglobin and fructosamine every 6 months for diabetes patients.

Quality indicators for the care of acute conditions included the following:

• Visits up to 4 weeks after discharge after hospitalization for acute MI, unstable angina, heart failure, cerebrovascular accident, TIA, diabetes, malignant or otherwise severe hypertension, or gastrointestinal bleed.

• Visits up to 2 weeks after discharge for patients hospitalized with depression.

• Visits up to 1 week after diagnosis of unstable angina (visit or hospitalization).

• ECG during emergency department visit for unstable angina.

• ECG up to 3 months after initial diagnosis of heart failure.

• ECG up 2 days of initial diagnosis of TIA.

• Chest radiograph up to 3 months after initial diagnosis of heart failure.

• Carotid imaging up to 2 weeks after initial diagnosis for patients hospitalized with carotid artery stroke.

• Carotid endarterectomy up to 2 months after carotid imaging for cerebrovascular accident patients with eventual carotid endarterectomy.

• Carotid endarterectomy up to 2 months after carotid imaging for TIA patients with eventual carotid endarterectomy.

• Cholecystectomy for patients with cholelithiasis plus cholecystitis, cholangitis, or gallstone pancreatitis.

• Arthroplasty or internal fixation of hip during hospital stay for hip fracture.

Among the study’s strengths, Dr. Snyder said that it examined the initial transition from acute cancer treatment to survivorship, an important time to ensure that survivors do not get lost in transition.

Discussant Lynne I. Wagner, Ph.D., of Northwestern University in Chicago said that this represented a novel contribution to the evidence base in survivorship care. "The comorbidity issues are extremely important. This is probably the tip of the iceberg in terms of what’s going on," she said.

The study was funded by the National Cancer Institute. Neither Dr. Snyder nor Dr. Wagner disclosed relevant relationships.