how well do we communicate with patients concerning adjuvant systemic therapy? a survey of 150...

How Well Do We Communicate with Patients How Well Do We Communicate with Patients Concerning Adjuvant Systemic Therapy?Concerning Adjuvant Systemic Therapy?

A Survey of 150 Colorectal Cancer SurvivorsA 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

BackgroundBackground

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

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 triple-negative breast cancer than to a patient at similar risk with colorectal cancer (Figure 1).

Background (continued)Background (continued)

46%

22%

81%

49%

90% 83%

10% risk ofrecurrence



How likely are you to recommend adjuvant chemotherapy to a 60-year-old woman with ER-negative breast cancer

or colorectal cancer? (% “very likely”)

100%

0%

ER-BC

CRC = Colorectal CancerER-BC = ER-Negative Breast Cancer

CRC CRC CRCER-BC

ER-BC

p < 0.01

p < 0.01p < 0.01

Survey of 150 Medical Oncologists (6/2006)Survey of 150 Medical Oncologists (6/2006)

FIGURE 1:


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.

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 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.

150 people with colorectal cancer who had

received adjuvant chemotherapy in the past five

years were recruited through advocacy groups

and oncology practices.

MethodsMethods

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)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.


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.


Tradeoff Situations PresentedTradeoff 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 2:

Sample Presentation of Case Scenario

Scenario 4• Baseline recurrence risk: 50%• Risk with chemotherapy: 45%

Would you receive treatment again?

Patients cured because ofadjuvant chemotherapy

Patients whose cancer wouldreturn even though they receivedadjuvant chemotherapy

Patients who were already curedwithout adjuvant chemotherapy

5

45

50

FIGURE 3:

• Absolute benefit: 5%

ResultsResults

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.

DemographicsDemographics

24%

76%

21%

47%

32%

Original Cancer Diagnosis

Colon

Rectum

Patient Age (Median = 55)

Over 65Under 50

• Gender: 67% female• Race: 86% Caucasian• Education: 79% with some college

50 to 65

FIGURE 4:

43%

52%

5%13%

67%

20%

Treatment ReceivedStage at Diagnosis

Stage III

Stage II Fluoropyrimidine

Fluoropyrimidine + Oxaliplatin

Demographics (continued)Demographics (continued)

OtherUnsure

FIGURE 4 (continued):

• 87% of patients were NED

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.

Results (continued)Results (continued)

Understanding of the Audio SegmentsUnderstanding of the Audio Segments

Segment 5 Strategy and Potential Benefits

of Adjuvant Therapy

Segment 6Risks of Therapy

22%5%

73%

11%

89%

I understood it completely or almost completely

I understood most of itI understood some of it

FIGURE 5:

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.


35% 36%

57%

68%77%

88%

0%

20%

40%

60%

80%

100%

1%

50% 49%

1%

20% 19%3%

20% 17%

5%

50% 45%

5%

20% 15%

10%

50% 40%

Reduction in Risk of Recurrence

FIGURE 6a:

Percent of Patients Who Would Be Percent of Patients Who Would Be Treated Again for Various Absolute Treated Again for Various Absolute

Reductions in Relapse RateReductions in Relapse Rate

0%

20%

40%

60%

80%

100%

Male Female

p = 0.630 p = 0.713 p = 0.584p = 1.000 p = 0.418 p = 0.290

1%

50% 49%

1%

20% 19%

3%

20% 17%

5%

50% 45%

5%

20% 15%

10%

50% 40%


32%36% 36% 36%

52%59%

70% 67%

80%76%

92%86%

FIGURE 6b: Percent of Patients Who Would Be Percent of Patients Who Would Be Treated Again for Various Absolute Treated Again for Various Absolute

Reductions in Relapse Rate (continued)Reductions in Relapse Rate (continued)

Treatment tradeoffs (Figures 6c-7)

• The responses of patients receiving oxaliplatin-containing 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.


0%

20%

40%

60%

80%

100%

Oxaliplatin No Oxaliplatin

p = 0.416 p = 0.922 p = 0.230p = 0.244 p = 0.117 p = 0.448


1%

50% 49%

1%

20% 19%

3%

20% 17%

5%

50% 45%

5%

20% 15%

10%

50% 40%

32%38%

32%

41%

51%

63%68% 68%

73%

82%86%

90%

FIGURE 6c: Percent of Patients Who Would Be Percent of Patients Who Would Be Treated Again for Various Absolute Treated Again for Various Absolute

Reductions in Relapse Rate (continued)Reductions in Relapse Rate (continued)

0%

20%

40%

60%

80%

100%

Physician Predictions vs Patient ResponsesPhysician Predictions vs Patient Responses

1%

50% 49%

1%

20% 19%

3%

20% 17%

5%

50% 45%

5%

20% 15%

10%

50% 40%


FIGURE 7:

19% 17%

35%

14% 10%

36%

28%

29%

57% 52%

59%

68%

48%

50%

77% 72%

83%

88%

Patients Clinical Investigators Medical Oncologists

Would you be treated again for this benefit?

Results (continued) 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 neuropathythan they expected.

3%

12%

42%

28%

15%Much more difficult

Somewhat more difficult

Similar

Somewhat easier

Much easier

Patient Expectations vs ExperiencePatient Expectations vs Experience

How similar was your overall experience with adjuvant chemotherapy compared to what your oncologist told you to expect?

FIGURE 8a:

How would you rate the following compared to what you expected?

Patient Expectations vs Experience (continued)Patient Expectations vs Experience (continued)

20%

23%

57%

7%

27%

66%

Nausea or Vomiting Hair Loss

Not as bad

About the same

Worse

* Patients receiving oxaliplatin-containing regimens

46%

35%

19%

38%

38%

24%

Cold Intolerance* Numbness in Fingers and Toes*

Not as bad

About the same

Worse

Not as bad

About the same

Worse

Not as bad

About the same

Worse

FIGURES 8b, c, d, e:



• 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.

Overall Care Provided

Patients’ Grading of Their OncologistsPatients’ Grading of Their Oncologists

0%

2%

6%

23%

69%

3%

5%

21%

27%

44%

Information Provided on Side Effects

A

B

C

D

F

A

B

C

D

F

FIGURE 9:



• 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.

26%

14%60%

Yes, participatedNo

Patient Participation in Clinical TrialsPatient Participation in Clinical Trials

Yes, declined

Were you offered participation in a clinical trial as part of your treatment?

FIGURE 10:

ConclusionsConclusions

• 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)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.

• 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.


• 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.


ReferencesReferences

1. Love N et al. Management of breast cancer in the adjuvant and metastatic settings. Patterns of Care in Medical Oncology 2007;4(1).

2. Love N, Goldberg RM. Management of cancer of the colon and rectum in the adjuvant and metastatic settings. Patterns of Care in Medical Oncology 2006;3(2).

3. Ravdin PM et al. Survey of breast cancer patients concerning their knowledge and expectations of adjuvant therapy. J Clin Oncol 1998;16(2):515-21.

4. Bremnes RM et al. Cancer patients, doctors and nurses vary in their willingness to undertake cancer chemotherapy. Eur J Cancer 1995;31A(12):1955-9.

5. Jansen SJ et al. Patients’ preferences for adjuvant chemotherapy in early-stage breast cancer: Is treatment worthwhile? Br J Cancer 2001;84(12):1577-85.

6. Coates AS, Simes RJ. Patient assessment of adjuvant treatment in operable breast cancer. In: Williams CJ, editor. Introducing new treatments for cancer: Practical, ethical and legal problems. London (UK): Wiley 1992. p 447-58.

7. Simes RJ, Coates AS. Patient preferences for adjuvant chemotherapy of early breast cancer: How much benefit is needed? J Natl Cancer Inst Monogr 2001;(30):146-52.

8. Love N et al. Patient perspectives on trade-offs of adjuvant systemic therapy for stage II and III colon cancer: A survey of 129 people with colorectal cancer. Gastrointestinal Cancers Symposium 2006;Abstract 373.

AcknowledgmentAcknowledgment

This work was supported by an education grant from Sanofi-Aventis.

how well do we communicate with patients concerning adjuvant systemic therapy? a survey of 150...

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