Time Toxicity in NSCLC: Understanding Healthcare Contact Days for Patients
—Investigators found that patients with stage IV non–small cell lung cancer spend, on average, approximately 30% of their 3.5 months of survival time with healthcare contact outside of the home.
Among patients diagnosed with stage IV non-small cell lung cancer (NSCLC), approximately 1 in 3 of their remaining days are spent in a healthcare setting outside of the home, according to a study published in JAMA.
“The oncology community has recently started paying close attention to ‘time toxicity,’ or the time-related burdens of cancer care. We have previously demonstrated that patients with advanced-stage gastrointestinal cancers can spend 1 in 4 days alive with health care contact (coming back and forth to the clinic or hospitalized), all while surviving just a few months,” said two of the study’s authors, Arjun Gupta, MD, of the Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, and Timothy P. Hanna, MD, PhD, of the Division of Cancer Care and Epidemiology, Cancer Research Institute at Queens University, Kingston, Ontario, Canada, in an interview with Ƶ.
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“However, an unanswered question was what the patterns of these healthcare contact days look like in cancers with tremendous progress in terms of new drugs. For example, lung cancer has seen the approval and use of dozens of new drugs such as immunotherapy and targeted therapy since the mid-2010s. Thus, we evaluated the experiences of people diagnosed with advanced lung cancer in Ontario using provincial data from 2014- 2017.”
Exploring the burden and patterns of healthcare contact
The investigators looked at contact days and exposure to various forms of cancer therapy. The primary outcome was the number of contact days between the time of diagnosis and death. Systemic therapy was considered the primary exposure, classified into the following three subgroups:
- Cytotoxic chemotherapy only
- First or subsequent line of immunotherapy (with or without chemotherapy)
- First or subsequent line of targeted therapy
Of 5785 participants, the median overall survival (OS) was 108 days, with the most common type of cancer being adenocarcinoma (57.8%). The median number of healthcare contact days was 36 (33.3%). Among patients who did not receive systemic therapy (n=3800), OS was 66 days, with a median 28 (42.4%) contact days.
Conversely, the patients who did receive systemic therapy (n=1985) had an OS of 261 days, with a median 59 (22.6%) contact days. For those receiving 1 line of therapy, the median OS and contact days (respectively) were as follows:
- 188 and 50 for cytotoxic chemotherapy OS
- 215 and 51 for immunotherapy
- 269 and 52 for targeted therapy
Overall, the percentage of total weekly contact days followed a U-shaped trajectory, the authors noted. Contact days were high right after diagnosis, decreasing in the middle period, and then another peak in the month prior to death (29.4%, 20.7%, and 36.5%, respectively). For outpatient contact days, the high was 19.3% after diagnosis and then a constant decline to 7.3% before death. Inpatient contact days were approximately 10% until the midway point, then an increase to roughly 29% until death.1
Contact days were associated with physical symptoms in the first month and mood-based symptoms in the lowest contact month. The authors point out that this emphasizes the need for psychosocial support even when physical symptoms are not prevalent.
Looking at patients who were administered systemic therapy, the institution-based contact increased, and the outpatient contact decreased over time. The rates did not differ by the time of the start of systemic therapy. The contact days increased acutely after therapy was finished until death. For the patients who received 1 line of therapy, the fewest contact days were experienced by those who were administered targeted therapy (10.6%) vs immunotherapy (15.4%) and chemotherapy (17.7%).1
The factors affecting contact days for patients who did not receive systemic therapy were urban residence and higher comorbidity, which were associated with more contact days in the first month. These patients who did not receive systemic treatments were older, had more comorbidities, and higher burden of symptoms, in addition to having a higher rate of squamous cell carcinoma.1
The need for psychosocial support and symptom management
In discussing the clinical implications of their study, Drs. Gupta and Hanna commented, “These findings are sobering, and are a call for the oncology community to recognize what patients and care partners go through while receiving cancer care, and how their lives can be consumed by cancer care, even in the more contemporary era of newer and supposedly less toxic treatments. We need to better prepare and support patients with cancer for expected time burdens, as we continue to work toward benchmark appropriateness and optimize care.”
Looking ahead
About future studies, Drs. Gupta and Hanna said, “There are 3 areas we need to pursue. First, we need to understand the impact of time toxicity for other cancers and other clinical situations. Second, we need to better understand what patients think about the time burdens of cancer care both at home and outside the home. Members of our team have started interviewing patients to understand what activities are considered the most burdensome, the consequences of those care activities on patients’ schedules, and what makes time spent to be perceived positively.”
“Third,” they concluded, “we need to explore how we can minimize the time burden of medical care on patients and their families. This could take the form of technological advances allowing us to monitor patients and deliver care at home more efficiently, or could mean advances in treatment that require fewer visits to the clinic.”
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