Cancer

1. Adherence to Surveillance Care Guidelines After Breast
and Colorectal Cancer Treatment with Curative Intent
Ramzi G Salloum, PhD
Department of Health Policy & Management, University of North Carolina at Chapel Hill
Center for Health Policy and Health Services Research, Henry Ford Health System
18th Annual HMORN Conference – Seattle, WA – 1 May 2012

2. Adherence to Surveillance Care Guidelines
 Ramzi G Salloum, PhD
 Mark C Hornbrook, PhD
 Paul A Fishman, PhD
 Debra P Ritzwoller, PhD
 Maureen C O’Keeffe Rosetti, MS
 Jennifer Elston Lafata, PhD
 Funding:
 NCI Grant No. R01 CA114204, PI: Mark Hornbrook, PhD
 Medical Care Burden of Cancer: System and Data Issues
 NCI Grant No. R25 CA116339, Co-PIs: Peggy Leatt, PhD and Bryan Weiner,
PhD
 Cancer Care Quality Training Program (Ramzi Salloum)
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3. Background
 In 2006, the IOM recommended cancer survivors receive
ongoing surveillance care based on a clearly and
effectively explained follow-up plan.
 Evidence- and consensus-based guidelines from
NCCN, ASCO, and others outline recommended
schedules for ongoing surveillance care after cancer
treatment with curative intent.
 Prior studies found deviations in surveillance care
patterns relative to evidence-based guidelines and
variations by sociodemographic characteristics.
 Studies have been mostly limited to 1 delivery
organization or Medicare (care received by survivors
aged ≤64 years is not well documented).
 To our knowledge no such studies have been conducted
since the IOM report.
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4. Aims
 Evaluation of extent to which surveillance care use
was consistent with guideline recommendations
 Cohorts of breast and colorectal cancer adult survivors
 4 geographically diverse health maintenance
organizations
 GHC
 HFHS
 KPCO
 KPNW
 Study period: 2000-2008
 Of specific interest was the evaluation of variability in
surveillance care use by age at diagnosis.
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5. Study population
 Inclusion criteria
 In situ, localized, and regional stage breast and colorectal
cancer
 Patients aged ≥18 years, diagnosed between 2000 and 2008
 1-year minimum continuous health plan enrollment prior to
diagnosis
 Exclusion criteria
 Previous diagnosis of invasive cancer
 Did not receive treatment with curative intent
 Females with bilateral mastectomy (breast cancer cohort)
 Index date
 3 months after curative surgical procedure
 End date
 Death, tumor recurrence, diagnosis of 2nd primary, health plan
disenrollment, 5 years after diagnosis, or end of follow-up
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6. Surveillance care receipt
 3 distinct types of surveillance testing:
 Physical examinations
 Testing for local recurrence
 Mammography, MRI, ultrasound (for breast cancer)
 Colonoscopy, sigmoidoscopy, barium enema (for colorectal
cancer)
 Testing for metastatic disease
 Chest radiograph
 Chest, abdomen, pelvis or head CT
 Chest, abdomen, pelvis or head MRI
 Bone, gallium, liver/spleen scan
 Abdominal or pelvic ultrasound
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7. Analytic approach
 Estimated time (in days) from index date to receipt of
minimum recommended surveillance test
 2 physical exams and 1 mammogram
 2 physical exams and 1 complete exam of the colon
 Percentage of patients who received recommended
care within 18 months of index date
 Kaplan-Meier estimates to evaluate median time to
initial and subsequent care receipt by type of
examination/test
 Cox proportional hazards models to account for
differing length of follow-up and describe risk of
receiving metastatic disease testing
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8. Sample characteristics by cancer site
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9. Time to receipt of physical examinations and local recurrence
and metastatic disease testing by service type and age
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10. Time from active treatment to surveillance:
Breast cancer survivors
Breast: 2 Physical Exams and 1 Mammogram
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0 6 12 18 24 30 36
Time in months from date of treatment with curative intent
Aged < 50 Aged 50-64
Aged 65-74 Aged 75+
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11. Time from active treatment to surveillance:
Colorectal cancer survivors
Colorectal: 2 Physical Exams and 1 Complete Exam of the Colon
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0 6 12 18 24 30 36
Time in months from date of treatment with curative intent
Aged < 50 Aged 50-64
Aged 65-74 Aged 75+
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12. Cox proportional hazards model:
Metastatic disease testing within 18 months
of treatment among breast cancer survivors
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13. Cox proportional hazards model:
Metastatic disease testing within 18 months
of treatment among colorectal cancer survivors
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14. Discussion
 Among geographically diverse cohorts of breast and
colorectal cancer survivors, we found deviations in
surveillance care relative to guideline recommendations.
 Overwhelming majority of breast and colorectal cancer
survivors received the minimum recommended physical
examinations.
 Majority of breast cancer survivors received
recommended recurrence testing, whereas nearly 1/2 of
colorectal cancer cohort failed to receive a complete
examination of the colon within 18 months of treatment.
 Greater than 67% of survivors, particularly
younger, received some type of metastatic disease
testing within 18 months.
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15. Limitations
 Study cohort members were limited to insured
individuals who received their cancer care from 1 of
4 integrated health care delivery systems.
 Unable to ascertain whether care received was for
surveillance versus other purposes.
 Grouping patients, with heterogeneity in
prognoses, into general disease stages.
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16. Future direction
 Compared with other phases of cancer control and
prevention, surveillance care among cancer survivors
appears to be understudied.
 Our findings highlight the wide variations in cancer
surveillance among seemingly clinically similar patients
and across different age groups.
 Need for research exploring whether observed variations
are driven by patient preferences and reflect informed
decision-making and how survivorship planning as
outlined by the IOM can impact such variations.
 Given the survival advantage for patients aged < 65
years, it is important to consider the care trajectory and
its implications among younger survivors.
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