Download Results (continued)

How Well Do We Communicate with Patients
Concerning Adjuvant Systemic Therapy?
A Survey of 150 Colorectal Cancer Survivors
Neil Love, MD1; Carma Bylund, PhD2; Neal J Meropol, MD3; John
L Marshall, MD4; Steven A Curley, MD5; Lee M Ellis, MD5; Axel
Grothey, MD6; Heinz-Josef Lenz, MD7; Leonard B Saltz, MD2;
Melanie Elder, BBA1; Kathryn Ault Ziel, PhD1;
Douglas Paley, BA1; Ginelle Suarez, BS1; Erin Wall, BS1
1 Research
To Practice, Miami, FL; 2 Memorial Sloan-Kettering Cancer Center,
New York, NY; 3 Fox Chase Cancer Center, Philadelphia, PA; 4 Lombardi
Comprehensive Cancer Center, Washington, DC; 5 The University of Texas MD
Anderson Cancer Center, Houston, TX; 6 Mayo Clinic College of Medicine, Rochester,
MN; 7 USC/Norris Comprehensive Cancer Center, Los Angeles, CA
Background
Clinical decision-making regarding adjuvant chemotherapy
for solid tumors presents a substantial patient education
challenge to medical oncologists for a number of reasons:
•
The treatment strategy is subtle and challenging
to explain to patients.
•
Potential benefits involve complex numeracy.
•
Potential risks of therapy may be substantial.
Despite these difficulties, clinicians are regularly called
upon to counsel patients about this treatment option, and
approximately one third of office visits for US-based medical
oncologists relate to adjuvant systemic therapy of breast,
colorectal and lung cancer.1
Background (continued)
Patterns of Care surveys conducted by our CME
group2 and other similar surveys3-5 indicate a
discrepancy in the way oncologists approach this
treatment strategy across tumor types.
For example, oncologists are more likely to
recommend chemotherapy to a woman with triplenegative breast cancer than to a patient at similar
risk with colorectal cancer (Figure 1).
FIGURE 1:
Survey of 150 Medical Oncologists (6/2006)
How likely are you to recommend adjuvant chemotherapy
to a 60-year-old woman with ER-negative breast cancer
or colorectal cancer? (% “very likely”)
90% 83%
81%
100%
p < 0.01
46%
49%
p < 0.01
p < 0.01
22%
ERCRC
BC
ERCRC
BC
ERCRC
BC
0%
10% risk of
recurrence
CRC = Colorectal Cancer
ER-BC = ER-Negative Breast Cancer
20% risk of
recurrence
30% risk of
recurrence
Background (continued)
Many factors may contribute to this dichotomy,
including a less well-established research database
supporting adjuvant therapy in colorectal cancer.
However, in breast cancer, a series of patient surveys
over the last 20 years has had an important impact on
the clinical practice of adjuvant therapy, including a
sentinel 1986 Australian study by Coates and Simes6, 7
of 104 women treated for breast cancer with adjuvant
CMF for six months that demonstrated that about half
would receive the same therapy again for a one percent
improvement in five-year overall survival.
Background (continued)
As no similar study had been conducted for patients
with colorectal cancer, our CME group launched
several needs assessment activities to understand
the perspectives of people in this clinical situation,
including:
•
A 2004 town meeting of survivors of colorectal
cancer and their loved ones
•
A 2005 survey of 150 people with varying stages
of colorectal cancer8
Our group initiated the current study to validate
and expand on previous findings by exploring the
experiences of people with colorectal cancer who
have recently received adjuvant chemotherapy.
Objectives
•
Evaluate patient attitudes and physician
beliefs regarding treatment tradeoffs in
colorectal cancer.
•
Document patient expectations of
chemotherapy and how these compared
to actual experiences.
Methods
150 people with colorectal cancer who had
received adjuvant chemotherapy in the past five
years were recruited through advocacy groups
and oncology practices.
Methods (continued)
These participants were asked to:
•
Listen to an audio education program featuring
interviews with clinical investigators and patients
to provide a standardized information platform.
•
Consider six theoretical case scenarios (Figure 2)
and corresponding graphics illustrating changes
in risk of relapse associated with adjuvant
chemotherapy (Figure 3).
•
Respond whether or not they would undergo their
previous chemotherapy regimen again for the
treatment benefit described in each scenario.
Methods (continued)
Participants were also asked to:
•
Complete an in-depth survey about their
expectations of and experiences with adjuvant
therapy and the quality of the care delivered and
information provided by their oncologists.
•
Evaluate the understandability, value and
relevance of an audio/web education supplement
to information provided in the oncology office.
Methods (continued)
A companion survey of 150 medical oncologists and
24 GI cancer specialists was conducted, and
participants were asked to consider the same six
scenarios evaluated by the patients and then
estimate the percent of patients in clinical practice
they thought would be willing to go through
chemotherapy for the benefits described.
FIGURE 2:
Tradeoff Situations Presented
Recurrence Risk
Scenario
Baseline
With Chemotherapy
Absolute Benefit
1
50%
49%
1%
2
20%
19%
1%
3
20%
17%
3%
4
50%
45%
5%
5
20%
15%
5%
6
50%
40%
10%
FIGURE 3:
Sample Presentation of Case Scenario
Scenario 4
•
Baseline recurrence risk: 50%
•
Risk with chemotherapy: 45%
•
Absolute benefit: 5%
Would you receive treatment again?
5
Patients cured because of
adjuvant chemotherapy
45
Patients whose cancer would
return even though they received
adjuvant chemotherapy
50
Patients who were already cured
without adjuvant chemotherapy
Results
Demographics (Figure 4)
•
Most participants were diagnosed with colon
cancer and had Stage III disease.
•
The median age was 55.
•
67 percent of the patients were female, 86 percent
were Caucasian and 79 percent had some college
education.
•
Approximately one half had received adjuvant
therapy with oxaliplatin and a fluoropyrimidine,
and the other half had mostly received a
fluoropyrimidine alone.
•
87 percent of the participants were free of
recurrence at the time of the survey.
FIGURE 4:
Demographics
Original Cancer Diagnosis
Patient Age (Median = 55)
50 to 65
Colon
47%
76%
24%
Rectum
•
•
•
Gender: 67% female
Race: 86% Caucasian
Education: 79% with some college
21%
Over 65
32%
Under 50
FIGURE 4 (continued):
Demographics (continued)
Stage at Diagnosis
Treatment Received
Fluoropyrimidine
+ Oxaliplatin
Stage III
67%
13%
Unsure
52%
43%
20%
5%
Other
Stage II
• 87% of patients were NED
Fluoropyrimidine
Results (continued)
Understanding of the audio education program
(Figure 5)
•
Most patients stated that they understood the
information completely or almost completely
despite the relatively sophisticated concepts
presented.
•
Most also believed that the program would be
relevant and of interest to other patients
diagnosed with colorectal cancer.
FIGURE 5:
Understanding of the Audio Segments
Segment 5
Strategy and Potential Benefits
of Adjuvant Therapy
Segment 6
Risks of Therapy
I understood it completely
or almost completely
89%
73%
5%
22%
I understood
some of it
11%
I understood most of it
Results (continued)
Treatment tradeoffs (Figures 6a-6b)
•
More than a third of the patients would be
treated again with the chemotherapy regimen
they previously received for a one percent
reduction in the risk of relapse.
•
More than 10 percent of the patients would not
receive treatment again even for a 10 percent
reduction in the risk of relapse.
•
The responses of men and women were not
statistically different.
FIGURE 6a:
Percent of Patients Who Would Be
Treated Again for Various Absolute
Reductions in Relapse Rate
100%
88%
77%
80%
68%
57%
60%
40%
35%
36%
1%
1%
3%
5%
5%
10%
50%  49%
20%  19%
20%  17%
50%  45%
20%  15%
50%  40%
20%
0%
Reduction in Risk of Recurrence
Percent of Patients Who Would Be
Treated Again for Various Absolute
Reductions in Relapse Rate (continued)
FIGURE 6b:
Male
Female
100%
92%
86%
80%
80%
70%
76%
67%
59%
60%
40%
20%
52%
32%
36%
36% 36%
p = 0.630
p = 1.000
p = 0.418
p = 0.713
p = 0.584
p = 0.290
1%
1%
3%
5%
5%
10%
50%  49%
20%  19%
20%  17%
50%  45%
20%  15%
50%  40%
0%
Reduction in Risk of Recurrence
Results (continued)
Treatment tradeoffs (Figures 6c-7)
•
The responses of patients receiving oxaliplatincontaining regimens compared to other regimens
were not statistically different despite the potential
increase in side effects and toxicity associated
with the addition of oxaliplatin.
•
The tradeoff predictions of practicing oncologists
and GI clinical investigators were lower than the
responses of the patients surveyed.
Percent of Patients Who Would Be
Treated Again for Various Absolute
Reductions in Relapse Rate (continued)
FIGURE 6c:
Oxaliplatin
No Oxaliplatin
100%
82%
86%
90%
73%
80%
68% 68%
63%
60%
40%
51%
41%
38%
32%
32%
p = 0.416
p = 0.244
p = 0.117
p = 0.922
p = 0.230
p = 0.448
1%
1%
3%
5%
5%
10%
50%  49%
20%  19%
20%  17%
50%  45%
20%  15%
50%  40%
20%
0%
Reduction in Risk of Recurrence
FIGURE 7:
Physician Predictions vs Patient Responses
Would you be treated again for this benefit?
Patients
Clinical Investigators
Medical Oncologists
100%
88%
83%
77%
80%
57%
60%
59%
52%
50%
48%
36%
35%
40%
20%
72%
68%
28% 29%
19%
17%
14%
10%
0%
1%
1%
3%
5%
5%
10%
50%  49%
20%  19%
20%  17%
50%  45%
20%  15%
50%  40%
Reduction in Risk of Recurrence
Results (continued)
Experiences and expectations (Figures 8-10)
•
More than half of the patients expected more
GI toxicity and alopecia than they
experienced, but more than one third of the
patients receiving oxaliplatin-containing
regimens experienced more troubling cold
intolerance and peripheral neuropathy than
they expected.
FIGURE 8a:
Patient Expectations vs Experience
How similar was your overall experience with adjuvant chemotherapy
compared to what your oncologist told you to expect?
15%
Much more difficult
28%
Somewhat more difficult
42%
Similar
Somewhat easier
Much easier
12%
3%
FIGURES 8b, c, d, e:
Patient Expectations vs Experience (continued)
How would you rate the following compared to what you expected?
Hair Loss
Nausea or Vomiting
Not as bad
About the
same
Worse
57%
Not as bad
About the
same
23%
20%
Worse
Cold Intolerance*
Not as bad
66%
7%
Numbness in Fingers and Toes*
Not as bad
24%
27%
About the
same
38%
About the
same
Worse
38%
Worse
* Patients receiving oxaliplatin-containing regimens
19%
35%
46%
Results (continued)
Experiences and expectations (Figures 8-10)
•
Most patients were satisfied with the quality
of care received from their medical
oncologists, but fewer were satisfied with
the amount of information provided on
potential side effects and treatment benefits.
FIGURE 9:
Patients’ Grading of Their Oncologists
Information Provided
on Side Effects
Overall Care Provided
69%
A
23%
B
C
6%
44%
A
27%
B
21%
C
D
2%
D
F
0%
F
5%
3%
Results (continued)
Experiences and expectations (Figures 8-10)
•
Most patients were not offered participation
in a clinical trial, and of those who were not,
more than 80 percent would have liked to
learn about research-based opportunities.
FIGURE 10:
Patient Participation in Clinical Trials
Were you offered participation in a clinical trial as part of your treatment?
No
Yes, participated
60%
14%
26%
Yes, declined
Conclusions
•
The perspectives of people with colorectal cancer
can be challenging to understand for those not
facing the experience firsthand, even oncology
professionals.
•
Physicians should consider that potential
heterogeneity exists in patient attitudes with
regard to the risk-benefit tradeoffs of adjuvant
chemotherapy, and individualized treatment
decisions should account for the perspectives
of that person.
Conclusions (continued)
•
Patients’ experiences with the side effects of
adjuvant chemotherapy may be quite different
than what they expect, and it is important to
consider that external information sources
such as other patients, friends and relatives
may be contributing to potential gaps in
physician-patient communication about
treatment-related toxicities.
Conclusions (continued)
•
These findings are limited by the potential bias
introduced because participants had previously
decided to receive adjuvant chemotherapy and
were generally free of recurrence. However, this
survey suggests an opportunity exists to
supplement information patients receive from
their oncologists.
Conclusions (continued)
•
To confirm these findings and explore how
improvements may be implemented, the next
step will be to conduct a prospective, real-time
evaluation of patients going through this
decision-making process and to evaluate the
impact of an audio/web program to enhance
physician-patient communication.
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Acknowledgment
This work was supported by
an education grant from Sanofi-Aventis.