ASCO Reading Room | Dr. Ishani Ganguli, on “Contact Days” with Health Care Among Older Survivors of Gynecologic and Other Cancers

Older survivors of gynecologic and other cancers spend a total of nearly a month each year—so-called health care contact days—receiving care outside their homes, the researchers reported. Most of this care was outpatient, often provided by non-oncologists, and influenced by a variety of factors beyond clinical characteristics.

Healthcare contact days represent an intuitive, practical, and patient-centered measure for understanding the proportion of a patient’s time spent interacting with the healthcare system, both in the hospital and outpatient settings, explained Dr. Arjun Gupta of the University of Minnesota in Minneapolis and colleagues. Previous studies, the team noted in their analysis JCO Oncology Practiceshowed that patients with advanced/metastatic aggressive cancer may spend a quarter of their days in contact with healthcare, but no study to date has examined contact days among long-term cancer survivors.

In the following interview, co-author Ishani Ganguli, MD, MPH, of Brigham and Women’s Hospital in Boston, discussed the study, which included a nationally representative sample of older adult cancer survivors.

What does the study add to the literature?

Lymph nodes: This study provides unprecedented national estimates of health care contact days, an indicator of potential health care burdens for older adults with cancer. We linked the 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days—that is, days spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice, or receiving outpatient care, including an office visit, procedure, treatment, imaging, or test—and described patterns in total and outpatient contact days.

The study uses a national sample of older adults with traditional Medicare who had cancer. It shows that these adults spent an average of 4 weeks (28 days) per year receiving health care outside of their home. Most of these days were spent on outpatient care such as doctor visits, tests, imaging scans, and treatments. Most tests, imaging scans, procedures, and treatments did not occur on the same day as an office visit, meaning doctors may miss opportunities to better coordinate care for patients.

We included 1,168 older adults representing 4.51 million cancer survivors—median age 76.4 years, 52.8% female. Median time since cancer diagnosis was 65 months. In 2019, these adults had a mean total contact days of 28.4 days and outpatient contact days of 24.2. These included days for testing (8), imaging (3.6), clinician visits (12.4), and visits to primary care clinicians (4.4) and non-oncology specialists (7.1) in particular.

About two-thirds (64%) of outpatient non-consultation days (e.g., examination) did not occur on the same day as a physician visit. Factors associated with more total consultation days included younger age, lower income, more chronic conditions, poor self-rated health, and a tendency to “go to the doctor whenever you feel unwell.”

What are the specific implications for patients with endometrial cancer?

Lymph nodes: We did not specifically study patients with endometrial cancer, but the above applies to these patients as well. In the current study, only 5.6% of cancer survivors had endometrial cancer or other gynecologic cancer.

Our lead author, Dr. Arjun Gupta, from the University of Minnesota, notes that another study on the toxicity of contact days/hours in patients with gynecologic cancers was presented at the 2023 Surgical Gynecologic Oncology Annual Meeting on Women’s Cancer. The results showed that patients with advanced recurrent endometrial cancer spent 15% of their treatment time interacting with healthcare.

A study by Gupta in patients with advanced gastrointestinal cancers reported a rate of about 25%, and other work in people with advanced cancer has found a rate of about 20%.

Generally, we find that for people with advanced stage 4 active cancer who are actively receiving cancer treatment, 15-25% of days are contact days, whereas for long-term cancer survivors who may have completed active cancer treatment (the subject of the current article), it is more like 1 month per year (about 8%), and these data likely apply to gynecologic cancer survivors as well.

What are the specific constraints faced by certain populations?

Lymph nodes: Patients had more contact days if they were younger, had lower incomes, had more chronic diseases, were in poorer health according to their own judgment, and reported that they tended to go to the doctor as soon as they felt unwell.

Our finding that outpatient services like tests and imaging studies were not performed on the same day as office visits tells us that we could, for example, find ways to combine testing with a more frequent visit to reduce the number of trips patients have to the clinic or hospital.

What is your main message for practicing oncologists?

Lymph nodes: Practicing oncologists can help reduce the burden of cancer survivorship care, even for those not undergoing active cancer treatment. As we note in our article: “These findings suggest ways to improve survivorship care, such as by improving clinical practice coordination and navigation, proactively addressing psychosocial care preferences, and creating, training, and convening a diverse cancer survivorship workforce.”

The findings highlight the need to recognize patient burden and improve the delivery of survivorship care, including through care coordination.

Read the study here and expert commentary on it here.