ASCO Reading Room | Important Findings on a Vastly Understudied Topic in Gynecologic Oncology

Cancer survivorship includes multiple phases of recovery, requiring different aspects of care for monitoring and preventing recurrent cancer and managing the long-term effects of cancer treatment. This area is not only largely understudied, but also particularly burdensome and challenging in the vulnerable population of older patients, who have significantly more comorbidities, putting them at higher risk during this phase.

Indeed, this population is at higher risk of progression or relapse, development of secondary cancers, and long-lasting physical symptoms or chronic toxicity due to cancer treatment. To this end, Arjun Gupta et al. studied “healthcare contact days,” including both outpatient and institutional care over a 1-year period, among cancer survivors aged 65 and older. This group presented their findings by quantifying and assessing key factors associated with time spent using health care among older cancer survivors.

As stated in JCO Oncology PracticeOf the 1,168 adults identified in the United States in 2019 in this retrospective study, an average of 28 days of health care contact were consumed over a 1-year period, which would be 1.5 times the average for this population and comparable to the number of contact days among older adults with multiple morbidities or frailty.

The vast majority of these days were spent in the outpatient setting, with patients often receiving only one type of service during an outpatient contact day; indeed, 65% of these services were not associated with a physician visit on the same day. Contact days with oncologists accounted for only about 3.7% of total contact days, while contact days with primary care physicians (4.7%) and non-oncology specialists (9.4%) were much higher.

The main factors associated with more contact days were: younger age, lower income, more comorbidities, poor self-rated health, and a tendency to “go to the doctor whenever you feel bad.” Cancer type also influenced contact day use, with lung cancer and leukemia being the most common.

About 20% of patients in the study reported poor health or difficulty getting to the doctor, leading to higher contact days. Alarmingly, a majority of patients in this analysis had more than 5 chronic conditions, and more than 30% of the study population reported living alone, and nearly 29% reported having functional impairment.

The study had several major limitations. In addition to being a retrospective analysis of a limited US database over a 1-year period in 2019, the population was predominantly Caucasian and metropolitan, with very few patients at the federal poverty level socioeconomically. Patients with end-stage renal disease were excluded, and another important exclusion was the use of virtual care (presumably including telemedicine and messaging via EHR portals) and home care, both of which are fundamental means of health care delivery, particularly in the modern/post-COVID era, including to geographically marginalized or functionally disabled populations who rely on them.

Of the six cancers included in the inclusion criteria, the majority of patients studied had breast or prostate cancer. Current chemotherapy and radiotherapy were considered, presumably maintenance or adjuvant treatments, although this calls into question whether some patients had an ongoing acute or chronic diagnosis, rather than being classified as survivors. Furthermore, no effort was made to conduct subgroup analyses by type of prior cancer treatment received, which would likely provide important context on future risk-adjusted healthcare needs that are prioritized or escalated appropriately.

While it is important to define and understand the factors that determine healthcare contact days in the context of survival, we must also avoid the overly simplistic and fundamental error of thinking that reducing an arbitrary measure leads to better outcomes. For example, consider the assumptions and nuances we accept in the current three-day hospital admission standard or penalties for readmission rates in sick patients. Indeed, providing care that is appropriate to the appropriate situation in the context is critical. To that end, I was pleased to read the authors’ attempt to explain their important limitation in quantifying the nuanced differences between appropriate and inappropriate overuse or underuse of healthcare that may have occurred in this population.

For example, inappropriate underuse could be present and of particular concern for populations underrepresented in this study, including those living in nonmetropolitan rural areas or of certain ethnicities, including Native American, Asian, and Hispanic populations, characterized in the study, who reported fewer contact days in the analysis. Conversely, there could also be overuse unrelated to cancer symptoms or even “fear-based,” which could lead to unnecessary testing or visits.

Another example of this logic is avoiding the simplistic assumption that all medical care can be delivered in a single day. While coupling outpatient services is ideal when possible in vulnerable populations, we know that, particularly in cancer care, there are circumstances in which complex diagnostic imaging, pathology stains, genomic testing, or laboratory testing must be performed well in advance so that these complex studies can be appropriately reviewed at the time of the clinic visit to provide a meaningful review of objective clinical data to guide that visit during the survivorship phase.

Overall, this paper presents important findings on a largely understudied topic, creating a platform on which future studies can delve into other nuances. Indeed, it is important to identify marginalized populations in cancer care and represent them more equitably in clinical trials.

Regardless, beyond the realm of associations or correlations that we achieve in large studies like this, the gold standard of scientific method in cause and effect requires that additional prospective studies be conducted in this area, with controlled and comparative intervention groups to impact this population in the most meaningful way.

Future trials could expand to cancers other than those studied in this study, including those requiring coordination between specialties such as surgical and radiation oncology, as well as maintenance or adjuvant therapies. Patients could also be stratified by type of treatment received, including cytotoxic chemotherapy, oncolytics, immunotherapy, radiation therapy, and surgery, to provide better context on the rate of necessary or unnecessary healthcare consumption.

As these analyses can be difficult to compare in aggregate, it would not be wrong to present case studies on specific circumstances and topics to highlight various variables critical to the effectiveness of cancer care in older adults.

The concept of missed opportunities to combine outpatient services and appointments could also be further explored. In particular, the use of cancer nurses and navigators should be explored as an intervention to improve not only appropriate healthcare use, but also patient experience, mental health, symptoms and outcomes.

Finally, it would be interesting to determine whether increasing the number of outpatient contact days or some other intervention would help reduce institutional contact days (i.e., emergency departments, hospitals, or nursing homes) that are arguably riskier.

Ultimately, to strengthen the survival period of all patients, it is important to view cancer care as a multidisciplinary disease and to deploy efforts with sufficient and prepared oncology staff from the time of diagnosis through treatment and post-treatment follow-up.

In my experience, while patients are often willing to discuss and prepare for the road ahead in terms of the established treatment plan, they do not always anticipate or understand the challenges of the long-term journey beyond the acute phase of treatment during the surveillance and survivorship phases, where they are more vulnerable to loss of follow-up or continuity and fragmentation of care.

In clinical practice, this phase of the pathway is often best conducted with physicians from oncology and non-oncology disciplines working closely together—ideally with geographic or relational proximity to ensure coordinated care. Indeed, in this study, clinic visits to primary care and non-oncology specialists not only outnumbered the number of days of contact with the oncologist, but the authors reported that having a primary care clinician as the predominant clinician was associated with better continuity of care, lower spending, and similar clinical outcomes.

Finally, as discussed above, there is also an underappreciated role (and unfortunate shortage) of cancer nurses and navigators to provide ongoing emotional support, early triage of any symptoms, and timely access to diagnostic studies, laboratory tests, preventive screenings, and referrals to ensure coordinated and effective implementation of post-treatment surveillance and survivorship.

Dr. Hardeep Phull is a physician-scientist, educator, author, and speaker involved in cancer care, personalized medicine, and healthcare innovation. At Palomar Health Medical Group in San Diego, he is the Director of Oncology. He is also the Alumni Specialty Director at Cleveland Clinic Lerner College of Medicine and a Clinical Instructor at the University of California, San Diego. You can also find him on X and Instagram.

Read the study here and an interview about it here.