Publications by authors named "Craig C Earle"

250 Publications

Building capacity for palliative care delivery in primary care settings: Mixed-methods evaluation of the INTEGRATE Project.

Can Fam Physician 2021 Apr;67(4):270-278

Palliative care physician in the Temmy Latner Centre for Palliative Care in the Sinai Health System in Toronto.

Objective: To evaluate an intervention aimed at building capacity to deliver palliative care in primary care settings.

Design: The INTEGRATE Project was a 3-year pilot project involving interprofessional palliative care education and an integrated care model to promote early identification and support of patients with palliative care needs. A concurrent mixed-methods evaluation was conducted using descriptive data, provider surveys before and after implementation, and interviews with providers and managers.

Setting: Four primary care practices in Ontario.

Participants: All providers in each practice were invited to participate. Providers used the "surprise question" as a prompt to determine patient eligibility for inclusion.

Main Outcome Measures: Provider attitudes toward and confidence in providing palliative care, use of palliative care tools, delivery of palliative care, and perceived barriers to delivering palliative care.

Results: A total of 294 patients were identified for early initiation of palliative care, most of whom had multiple comorbid conditions. Results demonstrated improvement in provider confidence to deliver palliative care (30% mean increase, < .05) and self-reported use of palliative care tools and services (25% mean increase, < .05). There was substantial variation across practices regarding the percentage of patients identified using the surprise question (0.2% to 1.5%), the number of advance care planning conversations initiated (50% to 90%), and mean time to conversation (13 to 76 days). This variation is attributable, in part, to contextual differences across practices.

Conclusion: A standardized model for the early introduction of palliative care to patients can be integrated into the routine practice of primary care practitioners with appropriate training and support. Additional research is needed to understand the practice factors that contribute to the success of palliative care interventions in primary care and to examine patient outcomes.
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http://dx.doi.org/10.46747/cfp.6704270DOI Listing
April 2021

Canadian Cancer Centre Response to COVID-19 Pandemic: A National and Provincial Response.

Curr Oncol 2020 12 31;28(1):233-251. Epub 2020 Dec 31.

Section of Hematology/Oncology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada.

Background: COVID-19 has spread rapidly, requiring health delivery systems to undertake dramatic transformations. To evaluate these system changes, we undertook one of the first Canadian health delivery system reviews and the first Canadian cancer centre evaluation of pandemic system modifications.

Methods: Questionnaires were distributed to the Canadian Association of Provincial Cancer Agencies (CAPCA) members in order to assess changes to cancer centre services and patient management. Documentation relating to COVID-19 from the CAPCA electronic space was accessed, and all publicly available cancer centre documentation related to COVID-19 was reviewed.

Results: Seven provinces completed the questionnaire and had documentation available from the CAPCA electronic space. All screening programs across Canada were suspended. In most provinces surveyed, ≥50% of outpatient appointments were occurring virtually, with <25% using video platforms. Generally, the impact on diagnostic imaging and new patient referrals correlated with the impact of COVID-19. Most provinces had a reduction in operating room availability, with chemotherapy and radiation treatments continuing. Public health modification, including personal protective equipment and screening staff, varied across the country.

Conclusion: Canadian cancer centres underwent a rapid and aggressive transformation of services in response to COVID-19, with many similarities and differences across provinces. In part, this response was facilitated by communication under a national association, which in Canada remains unique to cancer. This response may serve to inform changes in other jurisdictions or disease states now and in future waves of the pandemic, as well as a record of changes for future health services and patient outcome research.
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http://dx.doi.org/10.3390/curroncol28010026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900889PMC
December 2020

The cost of chemotherapy administration: a systematic review and meta-analysis.

Eur J Health Econ 2021 Mar 9. Epub 2021 Mar 9.

Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 011, Toronto, ON, M4N 3M5, Canada.

Purpose: Cancer treatment is a significant driver of healthcare costs worldwide, however, the economic impact of treating patients with anti-neoplastic agents is poorly elucidated. We conducted a systematic review and meta-analysis to estimate the direct costs associated with administering intravenous chemotherapy in an outpatient setting.

Methods: We systematically searched four databases from 2010 to present and extracted hourly administration costs and the respective components of each estimate. Separate analyses were conducted of Canadian and United States (US) studies, respectively, to address a priori hypotheses regarding heterogeneity amongst estimates. The Drummond checklist was used to assess risk-of-bias. Data were summarized using medians with interquartile ranges and five outliers were identified; costs were presented in 2019 USD.

Results: Forty-four studies were analyzed, including sub-analyses of 19 US and seven Canadian studies. 26/44 studies were of moderate-high quality. When components of administration cost were evaluated, physician costs were reported most frequently (24 studies), followed by lab tests (13) and overhead costs (9). The median estimate (excluding outliers) was $142/hour (IQR = $103-166). The median administration cost in the US was $149/hour (IQR = $118-158), and was $128/hour (IQR = $102-137) in Canada.

Conclusions: There is currently a paucity of literature addressing the costs of chemotherapy administration, and existing studies utilize a patchwork of reporting methodologies which renders direct comparison challenging. Our results demonstrate that the cost of administering chemotherapy is approximately $125-150/hour, globally. This value is dependent upon the region of analysis, inclusiveness of cost subcomponents as well as the methodology used to estimate unit prices, as described here.
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http://dx.doi.org/10.1007/s10198-021-01278-0DOI Listing
March 2021

Comparison of Multiparametric Magnetic Resonance Imaging-Targeted Biopsy With Systematic Transrectal Ultrasonography Biopsy for Biopsy-Naive Men at Risk for Prostate Cancer: A Phase 3 Randomized Clinical Trial.

JAMA Oncol 2021 Apr;7(4):534-542

Toronto General Hospital, Department of Radiology, University of Toronto, Toronto, Ontario, Canada.

Importance: Magnetic resonance imaging (MRI) with targeted biopsy is an appealing alternative to systematic 12-core transrectal ultrasonography (TRUS) biopsy for prostate cancer diagnosis, but has yet to be widely adopted.

Objective: To determine whether MRI with only targeted biopsy was noninferior to systematic TRUS biopsies in the detection of International Society of Urological Pathology grade group (GG) 2 or greater prostate cancer.

Design, Setting, And Participants: This multicenter, prospective randomized clinical trial was conducted in 5 Canadian academic health sciences centers between January 2017 and November 2019, and data were analyzed between January and March 2020. Participants included biopsy-naive men with a clinical suspicion of prostate cancer who were advised to undergo a prostate biopsy. Clinical suspicion was defined as a 5% or greater chance of GG2 or greater prostate cancer using the Prostate Cancer Prevention Trial Risk Calculator, version 2. Additional criteria were serum prostate-specific antigen levels of 20 ng/mL or less (to convert to micrograms per liter, multiply by 1) and no contraindication to MRI.

Interventions: Magnetic resonance imaging-targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS), v 2.0, score of 3 or greater was identified vs 12-core systematic TRUS biopsy.

Main Outcome And Measures: The proportion of men with a diagnosis of GG2 or greater cancer. Secondary outcomes included the proportion who received a diagnosis of GG1 prostate cancer; GG3 or greater cancer; no significant cancer but subsequent positive MRI results and/or GG2 or greater cancer detected on a repeated biopsy by 2 years; and adverse events.

Results: The intention-to-treat population comprised 453 patients (367 [81.0%] White, 19 [4.2%] African Canadian, 32 [7.1%] Asian, and 10 [2.2%] Hispanic) who were randomized to undergo TRUS biopsy (226 [49.9%]) or MRI-TB (227 [51.1%]), of which 421 (93.0%) were evaluable per protocol. A lesion with a PI-RADS score of 3 or greater was detected in 138 of 221 men (62.4%) who underwent MRI, with 26 (12.1%), 82 (38.1%), and 30 (14.0%) having maximum PI-RADS scores of 3, 4, and 5, respectively. Eighty-three of 221 men who underwent MRI-TB (37%) had a negative MRI result and avoided biopsy. Cancers GG2 and greater were identified in 67 of 225 men (30%) who underwent TRUS biopsy vs 79 of 227 (35%) allocated to MRI-TB (absolute difference, 5%, 97.5% 1-sided CI, -3.4% to ∞; noninferiority margin, -5%). Adverse events were less common in the MRI-TB arm. Grade group 1 cancer detection was reduced by more than half in the MRI arm (from 22% to 10%; risk difference, -11.6%; 95% CI, -18.2% to -4.9%).

Conclusions And Relevance: Magnetic resonance imaging followed by selected targeted biopsy is noninferior to initial systematic biopsy in men at risk for prostate cancer in detecting GG2 or greater cancers.

Trial Registration: ClinicalTrials.gov Identifier: NCT02936258.
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http://dx.doi.org/10.1001/jamaoncol.2020.7589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863017PMC
April 2021

Salvage surgery for locally recurrent anal cancer after intensity modulated radiation therapy with concurrent chemotherapy.

Cancer Treat Res Commun 2021 17;26:100287. Epub 2020 Dec 17.

Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada. Electronic address:

Introduction: Chemoradiation (CRT) with intensity modulated radiation treatment (IMRT) has become the standard for anal cancer. In patients who fail this treatment modality, salvage surgery with abdominal perineal resection can result in long term cancer control. We aimed to evaluate a single centre's experience of salvage surgery for local recurrence since the introduction of IMRT.

Materials And Methods: A retrospective chart review was performed of all patients who underwent definitive CRT for anal carcinoma at a single tertiary referral center since IMRT became standard in 2009. Patients with recurrent or persistent disease after treatment who underwent salvage surgery were included. Details of CRT, salvage surgery and surgical complications, patterns of recurrence after surgery, and survival data were collected and described.

Results: Between 2009-2018, 181 patients underwent definitive treatment using IMRT for anal carcinoma. Of 26 patients who had locoregional recurrent or persistent disease, 14 underwent salvage surgery. Nine had multi-visceral resection and 8 required autologous flap reconstruction. Twelve patients had resections with clear margins and 2 had microscopic positive margins. Twelve patients (86%) experienced post-operative complications, and eight (57%) had perineal wound complications. After salvage, four patients (29%) recurred locally. None of the 8 patients with rpT2 disease recurred. After salvage surgery, 5-year disease free survival was 68.4% and 5-year overall survival was 75%.

Conclusion: Following IMRT based chemoradiation, salvage surgery has high rates of surgical complications; however disease free and overall survival results are excellent particularly for small recurrences.
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http://dx.doi.org/10.1016/j.ctarc.2020.100287DOI Listing
December 2020

Impact of Geography on Care Delivery and Survival for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis.

J Natl Compr Canc Netw 2020 12 2;18(12):1642-1650. Epub 2020 Dec 2.

2Cancer Program - Evaluative Clinical Sciences, and.

Background: Little is known about how the geographic distribution of cancer services may influence disparities in outcomes for noncurable pancreatic adenocarcinoma. We therefore examined the geographic distribution of outcomes for this disease in relation to distance to cancer centers.

Methods: We conducted a retrospective population-based analysis of adults in Ontario, Canada, diagnosed with noncurable pancreatic adenocarcinoma from 2004 through 2017 using linked administrative healthcare datasets. The exposure was distance from place of residence to the nearest cancer center providing medical oncology assessment and systemic therapy. Outcomes were medical oncology consultation, receipt of cancer-directed therapy, and overall survival. We examined the relationship between distance and outcomes using adjusted multivariable regression models.

Results: Of 15,970 patients surviving a median of 3.3 months, 65.6% consulted medical oncology and 38.5% received systemic therapy. Regions with comparable outcomes were clustered throughout Ontario. Mapping revealed regional discordances between outcomes. Increasing distance (reference, ≤10 km) was independently associated with lower likelihood of medical oncology consultation (relative risks [95% CI] for 11-50, 51-100, and ≥101 km were 0.90 [0.83-0.98], 0.78 [0.62-0.99], and 0.77 [0.55-1.08], respectively) and worse survival (hazard ratios [95% CI] for 11-50, 51-100, and ≥101 km were 1.08 [1.04-1.12], 1.17 [1.10-1.25], and 1.10 [1.02-1.18], respectively), but not with likelihood of receiving therapy. Receipt of therapy seems less sensitive to distance, suggesting that distance limits entry into the cancer care system via oncology consultation. Regional outcome discordances suggest inefficiencies within and protective factors outside of the cancer care system.

Conclusions: These findings provide a basis for clinicians to optimize their practices for patients with noncurable pancreatic adenocarcinoma, for future studies investigating geographic barriers to care, and for regional interventions to improve access.
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http://dx.doi.org/10.6004/jnccn.2020.7605DOI Listing
December 2020

Real-world, population-based cohort study of toxicity and resource utilization of second-line ipilimumab for metastatic melanoma in Ontario, Canada.

Int J Cancer 2021 Apr 7;148(8):1910-1918. Epub 2020 Nov 7.

Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.

Second-line ipilimumab has been publicly funded in Ontario for metastatic melanoma (MM) since September 2012. We examined real-world toxicity of second-line ipilimumab compared to standard second-line treatments prior to funding. MM patients who received systemic treatment from April 2005 to March 2015 were included. Patients receiving second-line ipilimumab after September 2012 were considered as cases, and those who received second-line treatment prior to the funding date were included as historical controls. Outcomes assessed include treatment-related mortality, any-cause hospital visits, ipilimumab-related hospital visits and specialist visits (eg, endocrinologists, ophthalmologists, gastroenterologists, rheumatologists and respirologists), which were captured from up to 30 and/or 90 days after end of second-line treatment. Inverse probability of treatment weighting was used to adjust for baseline differences between groups. Odds ratios (ORs) from logistic regressions and rate ratios (RRs) from rate regressions were used to assess differences between groups. We identified 329 MM patients who received second-line treatments (ipilimumab: 189; controls: 140). Ipilimumab was associated greater any-cause (60.1% vs 45.7%; OR = 1.81; P value = .019) and ipilimumab-related (47.2% vs 31.9%; OR = 1.91; P value = .011) hospital visits. Adjusting for different follow-up days, ipilimumab was associated with higher rates of all-cause (RR = 1.56 [95%CI: 1.12-2.16]), and ipilimumab-related (RR = 2.18 [95% CI: 1.45-3.27]) hospital visits. Patients receiving ipilimumab were more likely to visit specialist involved in immunotherapy toxicity management (23.5% vs 13.7%; P value = .04). Compared to historical second-line treatments, second-line ipilimumab was associated with more health service utilization (specifically hospital visits and specialist visits), suggestive of potentially increased toxicity in the real world.
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http://dx.doi.org/10.1002/ijc.33357DOI Listing
April 2021

Real-World Costs of Azacitidine Treatment in Patients With Higher-Risk Myelodysplastic Syndromes/Low Blast-Count Acute Myeloid Leukemia.

JCO Oncol Pract 2021 Apr 21;17(4):e517-e525. Epub 2020 Sep 21.

Division of Hematology/Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

Purpose: Azacitidine (AZA) is a standard of care for higher-risk myelodysplastic syndrome (MDS)/low blast-count acute myeloid leukemia (AML). Despite this, there is a paucity of data on the real-world health care resource utilization costs of AZA in this population.

Methods: We linked the Ontario AZA MDS registry-higher-risk MDS/low blast-count AML-to population-based health system administrative databases. Patients were observed for 24 months after first AZA and censored at the earliest of 90 days after last AZA, date of death, time of AML induction/stem-cell transplantation, or March 31, 2016. Costs (2015 Canadian dollars) were expressed as standardized mean and median 28-day costs. Univariable quantile regression was used to explore the association of baseline patient and disease characteristics and median cost. Multivariable quantile regression was used to explore predictors of median costs.

Results: Among 877 patients in the registry, mean standardized 28-day cost per patient was $17,638 (median, $15,272; interquartile range [IQR], $11,869-$19,580) and $13,450 (median, $11,043; IQR, $7,981-$14,882) excluding the cost of AZA. Major nondrug drivers of cost were cancer clinic visits and inpatient care (mean standardized 28-day cost, $4,631; median, $1,558; IQR, $238-$4,961). Transfusion dependence at AZA initiation ( = .001) and greater comorbid disease burden ( = .009) were independently associated with increased cost.

Conclusion: Our cohort of patients with uniformly higher-risk MDS/low blast-count AML treated with AZA demonstrates substantial costs of care above and beyond the cost of AZA alone. These results provide insight into the costs of AZA in the real world with implications for resource allocation.
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http://dx.doi.org/10.1200/OP.20.00446DOI Listing
April 2021

The impact of routine Edmonton symptom assessment system use on receiving palliative care services: results of a population-based retrospective-matched cohort analysis.

BMJ Support Palliat Care 2020 Sep 17. Epub 2020 Sep 17.

Institute for Clincal Evaluative Sciences, Toronto, Ontario, Canada.

Background: In 2007, Cancer Care Ontario began standardised symptom assessment as part of routine care using the Edmonton Symptom Assessment System (ESAS).

Aim: The purpose of this study was to evaluate the impact of ESAS on receipt of palliative care when compared with a matched group of unexposed patients.

Design: A retrospective-matched cohort study examined the impact of ESAS screening on initiation of palliative care services provided by physicians or homecare nurses. The study included adult patients diagnosed with cancer between 2007 and 2015. Exposure was defined as completing ≥1 ESAS during the study period. Using 4 hard and 14 propensity score-matched variables, patients with cancer exposed to ESAS were matched 1:1 to those who were not. Matched patients were followed from first ESAS until initiation of palliative care, death or end of study.

Results: The final cohort consisted of 204 688 matched patients with no prior palliative care consult. The pairs were well matched. The cumulative incidence of receiving palliative care within the first 5 years was higher among those exposed to ESAS compared with those who were not (27.9% (95% CI: 27.5% to 28.2%) versus 27.9% (95% CI: 27.5% to 28.2%)), when death is considered as a competing event. In the adjusted cause-specific Cox proportional hazards model, ESAS assessment was associated with a 6% increase in palliative care services (HR: 1.06, 95% CI: 1.04 to 1.08).

Conclusion: We have demonstrated that patients exposed to ESAS were more likely to receive palliative care services compared with patients who were not exposed. This observation provides real-world data of the impact of routine assessment with a patient-reported outcome.
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http://dx.doi.org/10.1136/bmjspcare-2020-002220DOI Listing
September 2020

Directly Mailing gFOBT Kits to Previous Responders Being Recalled for Colorectal Cancer Screening Increases Participation.

J Can Assoc Gastroenterol 2020 Oct 18;3(5):197-203. Epub 2019 Oct 18.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Background: Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces CRC-related death. Average risk individuals should be recalled for screening with gFOBT every 2 years in order to maximize effectiveness. However, adherence with repeated testing is often suboptimal. Our aim was to evaluate whether adding a gFOBT kit to a mailed recall letter improves participation compared with a mailed recall letter alone, among previous responders to a mailed invitation.

Methods: We conducted a cluster randomized controlled trial, with the primary care provider as the unit of randomization. Eligible patients had completed a gFOBT and tested negative in an earlier pilot study and were now due for recall. The intervention group received a mailed CRC screening recall letter from their primary care provider plus a gFOBT kit ( = 431) while the control group received a mailed CRC screening mailed recall letter alone ( = 452). The primary outcome was the uptake of gFOBT or colonoscopy within 6 months.

Results: gFOBT uptake was higher in the intervention group (61.3%, = 264) compared with the control group (50.4%, = 228) with an absolute difference between the two groups of 10.8% (95% confidence interval [CI]: 1.4 to 20.2%, = <0.01). Patients in the intervention group were more likely to complete the gFOBT compared with the control group (odds ratio [OR] = 1.4; 95% CI: 1.1 to 1.9).

Conclusion: Our findings show that adding gFOBT kits to the mailed recall letter increased participation among persons recalled for screening. Nine gFOBT kits would have to be sent by mail in order to screen one additional person.
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http://dx.doi.org/10.1093/jcag/gwz012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464595PMC
October 2020

The impact of routine Edmonton Symptom Assessment System (ESAS) use on overall survival in cancer patients: Results of a population-based retrospective matched cohort analysis.

Cancer Med 2020 10 14;9(19):7107-7115. Epub 2020 Aug 14.

Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.

Background: The Edmonton Symptom Assessment System (ESAS) is a validated instrument whose use has been standardized in the Ontario cancer system to measure symptoms among ambulatory cancer patients. The objective was to examine the effect of ESAS exposure on overall survival. We hypothesized, a priori, that patients exposed to ESAS would have higher rates of overall survival than those who were not exposed.

Methods: This was a retrospective matched cohort study of adults diagnosed with cancer between 2007 and 2015. Patients were considered exposed if they were screened with ESAS at least once during the study period. Their first ESAS screening date defined the index date. Each exposed patient was matched randomly to a cancer patient without ESAS using a combination of hard matching (4 variables) and propensity score matching (14 variables). Kaplan-Meier curves and multivariable Cox regression were used to evaluate the impact of ESAS exposure on survival.

Results: There were 128,893 pairs well matched on all baseline characteristics. The probability of survival within the first 5 years was higher among those exposed to ESAS compared to those who were not (81.9% vs. 76.4% at 1 year, 68.3% vs. 66.1% at 3 years, 61.9% vs. 61.4% at 5 years, P-value < .0001). In the multivariable Cox regression model, ESAS was significantly associated with a decreased mortality risk (HR: 0.48, 95% CI: 0.47-0.49).

Conclusions: Our results show that ESAS exposure is associated with improved survival in cancer patients. This provides real world evidence of the impact of routine symptom assessment in cancer care.
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http://dx.doi.org/10.1002/cam4.3374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541161PMC
October 2020

Symptom Burden of Nonresected Pancreatic Adenocarcinoma: An Analysis of 10,753 Patient-Reported Outcome Assessments.

Pancreas 2020 09;49(8):1083-1089

ICES, Toronto.

Objectives: Pancreatic adenocarcinoma (PAC) is a debilitating disease. We sought to analyze symptom burden and trajectories after diagnosis of PAC and identify predictors of severe symptoms for nonresected patients.

Methods: This was a retrospective review of linked administrative health care databases examining patients with PAC not undergoing resection. Primary outcome was severe patient-reported symptoms (Edmonton Symptom Assessment System ≥7). Multivariable modified Poisson regression models were used to identify factors associated with reporting severe symptoms.

Results: A total of 10,753 symptom assessments from 2168 patients were analyzed. The median age was 67 years, and 47% were female; median survival was 7 months. Most common severe symptoms were tiredness (54.7%), anorexia (53.6%), overall impaired well-being (45.3%), and drowsiness (37.1%). Severity of symptoms decreased 1 month after diagnosis and plateaued 4 months after diagnosis. Female sex, comorbidities, and older age were associated with reporting severe symptoms; recent radiation treatment and residence in a rural community were associated with reporting less severe symptoms.

Conclusions: The prevalence of severe symptoms in patients with nonresected PAC was high, but potentially modifiable. We identified vulnerable groups of patients that may benefit from focused interventions. This information is important for patient counseling and design of supportive care strategies.
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http://dx.doi.org/10.1097/MPA.0000000000001629DOI Listing
September 2020

Material deprivation and access to cancer care in a universal health care system.

Cancer 2020 Oct 3;126(20):4545-4552. Epub 2020 Aug 3.

ICES, Toronto, Ontario, Canada.

Background: The role of socioeconomic factors as determinants of oncology consultations for advanced cancers in public payer health care systems is unknown. This study examined the association between material deprivation and receipt of cancer care among patients with advanced gastrointestinal (GI) cancer.

Methods: This was a population-based, retrospective cohort study of noncuratively treated patients with GI cancer diagnosed from 2007 to 2017. Material deprivation, representing income, quality of housing, education, and family structure, was defined as quintiles on the basis of 2016 census data. The first consultation with a radiation oncologist or medical oncologist and the receipt of 1 or more instances of radiation and/or chemotherapy were measured in the year after diagnosis. Adjusted, cause-specific Cox proportional hazards competing risk analyses were used (competing event = death).

Results: This study included 34,022 noncuratively treated patients with GI cancer. Consultation rates ranged from 67.8% for those in the most materially deprived communities to 73.5% for those in the least materially deprived communities. Among those with a consult, rates of cancer-directed therapy ranged from 58.5% for patients in the most materially deprived communities to 62.3% for patients in the least materially deprived communities. Patients living in the most materially deprived communities were significantly less likely to see a radiation and/or medical oncologist after a diagnosis (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.92) and significantly less likely to receive radiation and/or chemotherapy (HR, 0.80; 95% CI, 0.76-0.85) than those living in the least materially deprived communities.

Conclusions: This study identified socioeconomic disparities in accessing cancer care. Continued efforts at examining and developing evidence-based policies for interventions that begin before or at the time of oncologist consultation are required to address root causes of inequities.
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http://dx.doi.org/10.1002/cncr.33107DOI Listing
October 2020

The association between endocrine therapy use and dementia among post-menopausal women treated for early-stage breast cancer in Ontario, Canada.

J Geriatr Oncol 2020 09 29;11(7):1132-1137. Epub 2020 Jun 29.

Division of Medical Oncology, Sunnybrook Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; ICES Central, Toronto, Ontario, Canada.

Purpose: The association between endocrine therapy and risk of dementia remains uncertain. We investigated the association between adjuvant endocrine therapy for breast cancer and risk of developing dementia in a real-world, population-based study.

Methods: We used health administrative data collected from post-menopausal women (aged ≥66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2012 with follow-up until 2017. Patients were classified by the use of either an aromatase inhibitor or tamoxifen and followed to estimate the unadjusted cumulative incidence of developing dementia. A multivariable Cox proportional hazards model was created adjusting for age, income quintile, medical co-morbidities, and duration of endocrine therapy.

Results: We identified 12,077 patients of whom 73% were treated with an aromatase inhibitor and 27% with tamoxifen. Our multivariable analysis showed a lower rate of dementia in patients treated with an aromatase inhibitor as compared to tamoxifen [Hazard ratio (HR) = 0.88, 95% confidence interval (CI): 0.78-0.98, p-value = .02) at a median follow-up of 5.9 years. The 5-year dementia rate among patient treated with either an aromatase inhibitor or tamoxifen was 7.4% and 9.2% respectively. Older age, previous history of ischemic heart disease, diabetes, hypertension and history of stroke were all significantly associated with the development of dementia.

Conclusion: Aromatase inhibitor therapy was associated with a decreased incidence of dementia as compared to treatment with tamoxifen among post-menopausal women with early stage breast cancer. Further prospective studies with longer-term follow-up investigating the neurocognitive effects of endocrine therapy are warranted.
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http://dx.doi.org/10.1016/j.jgo.2020.05.009DOI Listing
September 2020

Impact of Standardized Edmonton Symptom Assessment System Use on Emergency Department Visits and Hospitalization: Results of a Population-Based Retrospective Matched Cohort Analysis.

JCO Oncol Pract 2020 09 28;16(9):e958-e965. Epub 2020 May 28.

Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.

Purpose: The Edmonton Symptom Assessment System (ESAS) is a validated instrument whose use has been standardized in the Ontario cancer system to measure symptoms among ambulatory patients with cancer. The objective was to examine the effect of ESAS exposure on visits to the emergency department (ED) and hospitalizations.

Methods: This was a retrospective matched cohort study conducted in Ontario, Canada. The study included patients ≥ 18 years of age diagnosed with cancer between 2007 and 2015. Patients were considered exposed if they were screened with ESAS at least once during the study period, and their first ESAS screening date was defined as the index date. Each exposed patient was matched randomly to a patient with cancer without ESAS assessment using a combination of hard matching (birth year ± 2 years, cancer diagnosis date ± 1 year, cancer type, and sex) and propensity score matching (14 variables, including cancer stage, treatments received, and comorbidities). A multivariable Andersen-Gill recurrent event model was used to evaluate the effect of ESAS on the rate of health care use.

Results: The analysis included 128,893 matched pairs that were well balanced on baseline measures. After adjusting for other variables, patients with ESAS had lower rates of both ED visits (relative rate [RR], 0.92; 95% CI, 0.91 to 0.93) and hospitalizations (RR, 0.86; 95% CI, 0.85 to 0.87) compared with patients without ESAS.

Conclusion: ESAS exposure is independently associated with decreased rates of ED visits and hospitalizations. This provides real-world evidence of one potential positive impact of standardized symptom assessment in cancer care.
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http://dx.doi.org/10.1200/JOP.19.00660DOI Listing
September 2020

Guidance for management of cancer surgery during the COVID-19 pandemic.

Can J Surg 2020 05;63(22):S2-S4

From the Canadian Partnership Against Cancer (Finley, Prashad, Camuso, Daly, Earle); the Canadian Network of Surgical Associations for Cancer Care (Aprikian, Ball, Bentley, Charest, Fata, Helyer, O'Connell, Moloo, Seely, Werier, Zhong); the Canadian Urological Association and the Division of Urology, Department of Surgery, McGill University, Montreal, Que. (Aprikian); the Canadian Hepato-Pancreatico-Biliary Association and the Department of Surgery, University of Calgary, Calgary, Alta. (Ball); the Society for Gynecologic Oncology of Canada and the Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, NS (Bentley); the Canadian Neurosurgical Society and the Department of Neurosurgery, Dalhousie University New Brunswick, Moncton, NB (Charest); the Canadian Association of General Surgeons and the Division of General Surgery, Department of Surgery, McGill University, Montreal, Que. (Fata); the Canadian Society of Surgical Oncology and the Department of General Surgery, Dalhousie University, Halifax, NS (Helyer); the Canadian Association of Head and Neck Surgical Oncology and the Division of Otolaryngology - Head and Neck Surgery, University of Alberta, Edmonton, Alta.(O'Connell); the Canadian Society of Colon and Rectal Surgeons and the Division of General Surgery, Department of Surgery, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ont. (Moloo); the Canadian Association of Thoracic Surgeons and the Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ont. (Seely); the Canadian Orthopaedic Oncology Society and the Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Werier); the Canadian Society of Plastic Surgeons and the Department of Surgery, University of Toronto, Toronto, Ont. (Zhong); the Department of Surgery, McMaster University, Hamilton, Ont. (Finley); the Department of Gastrointestinal Oncology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Earle); and the Canadian Journal of Surgery (Ball).

Summary: During the coronavirus disease 2019 (COVID-19) pandemic, delaying lifesaving cancer surgeries must be done with extreme caution and thoughtfulness. Modelling indicates that delays in high-risk cancer surgeries beyond 6 weeks could affect long-term outcomes for thousands of Canadians. Consequently, it is possible that postponing cancer surgery without consideration of its implications could cost more lives than can be saved by diverting all surgical resources to COVID-19. This article provides general guidance on supporting curative surgical treatment where appropriate and with available resources.
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http://dx.doi.org/10.1503/cjs.005620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828991PMC
May 2020

Healthcare resource utilization in myeloproliferative neoplasms: a population-based study from Ontario, Canada.

Leuk Lymphoma 2020 08 23;61(8):1908-1919. Epub 2020 Apr 23.

The Elizabeth and Tony Comper MPN Program, Princess Margaret Cancer Centre, Toronto, Canada.

Health resource utilization (HRU) and associated factors of high cost are not well understood in myeloproliferative neoplasms (MPNs). In this population-based, retrospective matched-cohort study, we used administrative health databases of Ontario, Canada to measure treatment costs and HRU for patients with MPN from 2004 to 2016 and compared them to matched controls. In 7130 patients with MPN [essential thrombocythemia (ET) = 3481; polycythemia vera (PV) = 2618; myelofibrosis (MF) = 1031], the mean annualized treatment costs were $16,646 for ET (controls, $7070); $16,360 for PV (controls, $7293); and $25,863 for MF (controls, $7386). Out of the total costs, the largest expenditure was on acute hospital care (ET: 57%, PV: 57%, MF: 66%). Older age (≥65), male gender, patients not seen by a specialist, and greater comorbidity burden were independent predictors of higher costs ( < 0.05). In addition, history of venous thrombosis in patients with ET and PV was associated with significantly higher treatment costs ( < 0.05).
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http://dx.doi.org/10.1080/10428194.2020.1749607DOI Listing
August 2020

Real-world comparative effectiveness of second-line ipilimumab for metastatic melanoma: a population-based cohort study in Ontario, Canada.

BMC Cancer 2020 Apr 15;20(1):304. Epub 2020 Apr 15.

Cancer Care Ontario, Toronto, ON, Canada.

Background: For novel cancer treatments, effectiveness in clinical practice is not always aligned with clinical efficacy results. As such it is important to understand a treatment's real-world effectiveness. We examined real-world population-based comparative effectiveness of second-line ipilimumab versus non-ipilimumab treatments (chemotherapy or targeted treatments).

Methods: We used a cohort of melanoma patients receiving systemic treatment for advanced disease since April 2005 from Ontario, Canada. Patients were identified from provincial drug databases and the Ontario Cancer Registry who received second-line ipilimumab from 2012 to 2015 (treated) or second-line non-ipilimumab treatment prior to 2012 (historical controls). Historical controls were chosen, to permit the most direct comparison to pivotal trial findings. The cohort was linked to administrative databases to identify baseline characteristics and outcomes. Kaplan-Meier curves and multivariable Cox regression models were used to assess overall survival (OS). Observed potential confounders were adjusted for using inverse probability of treatment weighting (IPTW).

Results: We identified 329 patients with metastatic melanoma (MM) who had received second-line treatments (189 treated; 140 controls). Patients receiving second-line ipilimumab were older (61.7 years vs 55.2 years) compared to historical controls. Median OS were 6.9 (95% CI: 5.4-8.3) and 4.95 (4.3-6.0) months for ipilimumab and controls, respectively. The crude 1-year, 2-year, and 3-year OS probabilities were 34.3% (27-41%), 20.6% (15-27%), and 15.2% (9.6-21%) for ipilimumab and 17.1% (11-23%), 7.1% (2.9-11%), and 4.7% (1.2-8.2%) for controls. Ipilimumab was associated with improved OS (IPTW HR = 0.62; 95% CI: 0.49-0.78; p < 0.0001).

Conclusions: This real-world analysis suggests second-line ipilimumab is associated with an improvement in OS for MM patients in routine practice.
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http://dx.doi.org/10.1186/s12885-020-06798-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158109PMC
April 2020

Comparison of outcomes in a population-based cohort of metastatic breast cancer patients receiving anti-HER2 therapy with clinical trial outcomes.

Breast Cancer Res Treat 2020 May 31;181(1):155-165. Epub 2020 Mar 31.

Department of Medicine, University of Toronto, Toronto, ON, Canada.

Purpose: Little data exist for comparing cardiac safety and survival outcomes of trastuzumab/pertuzumab or ado-T emtansine (TDM1) in metastatic breast cancer (MBC) patients enrolled in randomized clinical trial (RCT) vs the real-world.

Methods: This was a retrospective population-based cohort of all patients with MBC treated with trastuzumab/pertuzumab or TDM1 (2012-2017) in Ontario, Canada. Outcomes were incident heart failure (HF) and overall survival (OS). RCT data were obtained from digitizing survival curves and compared with cohort data using Kaplan-Meier analysis. Age-based comparison of outcomes was conducted for patients ≥ 65 years old vs younger than 65.

Results: The two cohorts composed of 833 and 397 patients treated with trastuzumab/pertuzumab and TDM1, of whom 5.5% and 7.6% had baseline HF, respectively. Incident HF following trastuzumab/pertuzumab or TDM1 was low (trastuzumab/pertuzumab 1.8 events/100 person years; TDM1 0.02 events/100 person years). The median OS was 39.2 and 56.4 months in the trastuzumab/pertuzumab population-based cohort and CLEOPATRA, respectively. The median OS was 15.4 and 30.9 months in the TDM1 population-based cohort and EMILIA, respectively. Cohort OS was significantly worse than RCT OS (trastuzumab/pertuzumab HR 1.67, 95% CI 1.37-2.03, p < 0.0001; TDM1 HR 2.80, 95% CI 2.27-3.44, p < 0.0001). Older patients had worse OS than younger patients for trastuzumab/pertuzumab (HR 1.60, 95% CI 1.19-2.16, p = 0.0018), but not for TDM1 (HR 1.16, 95% CI 0.81-1.66, p = 0.43).

Conclusion: HF incidence during trastuzumab/pertuzumab or TDM1 therapy in this real-world cohort was low. Survival in this cohort was worse compared to RCT, suggesting that recruitment of patients similar to the real-world population is required.
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http://dx.doi.org/10.1007/s10549-020-05614-5DOI Listing
May 2020

Assessing the Impact of Early Identification of Patients Appropriate for Palliative Care on Resource Use and Costs in the Final Month of Life.

JCO Oncol Pract 2020 08 20;16(8):e688-e702. Epub 2020 Mar 20.

Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Purpose: This study evaluates whether an intervention to identify Canadian patients eligible for a palliative approach changes the use of health care resources and costs within the final month of life.

Methods: Between 2014 and 2017, physicians identified 1,187 patients in family practice units and cancer centers who were likely to die within 1 year based on diagnosis, symptom assessment, and performance status. A multidisciplinary intervention that included activation of community resources and initiation of palliative planning was started. By using propensity-score matching, patients in the intervention group were matched 1:1 with nonintervention controls selected from provincial administrative data. We compared health care use and costs (using 2017 Canadian dollars) for 30 days before death between patients who died within the 1-year follow-up and matched controls.

Results: Groups (n = 629 in each group) were well-balanced in sociodemographic characteristics, comorbidities, and previous health care use. In the last 30 days, there was no differences in proportions between the two groups of patients regarding emergency department visits, intensive care unit admissions, or inpatient hospitalizations. However, patients in the intervention group had greater use of palliative physician encounters, community home care visits, and/or physician home visits (92.8% 88.4%; = .007). In the 507 pairs with cancer, more patients in the intervention group underwent chemotherapy (44% 33%; < .001) and radiation (18.7% 3.2%; = .043) in the last 30 days. Mean cost per patient was similar for the intervention group (mean, $17,231; 95% CI, $16,027 to $18,436) and for the control group (mean, $16,951; 95% CI, $15,899 to $18,004).

Conclusion: Even with the limitations in our observational study design, identification of palliative patients did not significantly change overall costs but may shift resources toward palliative services.
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http://dx.doi.org/10.1200/JOP.19.00397DOI Listing
August 2020

Health system costs for cancer medications and radiation treatment in Ontario for the 4 most common cancers: a retrospective cohort study.

CMAJ Open 2020 Jan-Mar;8(1):E191-E198. Epub 2020 Mar 16.

Sunnybrook Research Institute (Mittmann, Seung) and Odette Cancer Centre (Look Hong, Earle, Cheung, Coburn, DeAngelis), Sunnybrook Health Sciences Centre; Cancer Care Ontario (Mittmann), Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (Mittmann), Ottawa, Ont.; ICES (Liu, Cheng, Saxena, Earle, Cheung, Coburn); Health Outcomes and PharmacoEconomic (HOPE) Research Centre (Seung); University Health Network (Leighl), Toronto, Ont.; McMaster University (Evans), Hamilton, Ont.

Background: Previous costing and resource estimates for cancer have not been complete owing to lack of comprehensive data on cancer-related medication and radiation treatment. Our objective was to calculate the mean overall costs per patient of cancer-related medications and radiation, as well as by disease subtype and stage, in the first year after diagnosis for the 4 most prevalent cancers in Ontario.

Methods: We conducted a retrospective cohort study using provincial health administrative databases to identify population health system resources and costs for all patients diagnosed with breast, colorectal, lung or prostate cancer between Jan. 1, 2010, and Dec. 31, 2015 in Ontario. The primary outcome measure was the overall average cost per patient in the 365 days after diagnosis for cancer-related medications and radiation treatment, calculated with the use of 2 novel costing algorithms. We determined the cost by disease, disease subtype and stage as secondary outcomes.

Results: There were 168 316 Ontarians diagnosed with cancer during the study period, 50 141 with breast cancer, 38 108 with colorectal cancer, 34 809 with lung cancer and 45 258 with prostate cancer. The mean per-patient cost for cancer-related medications was $8167 (95% confidence interval [CI] $8023-$8311), $6568 (95% CI $6446-$6691), $2900 (95% CI $2816-$2984) and $1211 (95% CI $1175-$1247) for breast, colorectal, lung and prostate cancer, respectively. The corresponding mean radiation treatment costs were $18 529 (95% CI $18 415-$18 643), $15 177 (95% CI $14 899-$15 456), $10 818 (95% CI $10 669-$10 966) and $16 887 (95% CI $16 648-$17 125). In general, stage III and IV cancers were the most expensive stages for both medications and radiation across all 4 disease sites.

Interpretation: Our work updates previous costing estimates to help understand costs and resources critical to health care system planning in a single-payer system. More refined costing estimates are useful as inputs to allow for more robust health economic modelling and health care system planning.
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http://dx.doi.org/10.9778/cmajo.20190114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082106PMC
February 2021

Healthcare utilization in patients with higher-risk MDS/low-blast count AML treated with azacitidine in the 'real-world'.

Leuk Lymphoma 2020 06 8;61(6):1445-1454. Epub 2020 Feb 8.

Division of Hematology/Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.

Despite the adoption of azacitidine (AZA) in higher-risk MDS/low-blast count AML, limited 'real-world' data on resource utilization and toxicity exist. We linked the Ontario AZA-MDS registry to population-based administrative databases. Among 877 patients in the registry, 705 (80.4%) had at least one emergency department (ED) visit, 290 (33.1%) had an ED visit during their first cycle and 680 patients (77.5%) had at least one hospitalization (mean length 17.7 days, 95% CI 16.3-19.1). Older age, rurality, non-response to AZA, transfusion dependence, IPSS score, and greater comorbidity were independent predictors of increased ED visits; while greater comorbidity, non-response to AZA, and transfusion dependence were associated with longer hospitalization. When restricted to receiving ≥3 cycles, hospitalization during the first cycle was associated with increased risk of death. Our analysis of 'real-world' patients treated with AZA demonstrates significant healthcare utilization and increased risk of death for patients hospitalized during their first cycle. These results will inform patients/providers about 'real-world' toxicities of AZA.
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http://dx.doi.org/10.1080/10428194.2020.1723012DOI Listing
June 2020

Integration of patient-reported outcomes (PROs) for personalized symptom management in "real-world" oncology practices: a population-based cohort comparison study of impact on healthcare utilization.

Support Care Cancer 2020 Oct 4;28(10):4933-4942. Epub 2020 Feb 4.

ICES, Toronto, Ontario, Canada.

Background: The use of patient-reported outcomes (PROs) for routine cancer distress screening is endorsed globally as a quality-care standard. However, there is little research on the integration of PROs in "real-world" oncology practices using implementation science methods. The Improving Patient Experience and Health Outcome Collaborative (iPEHOC) intervention was established at multisite disease clinics to facilitate the use of PRO data by clinicians for precision symptom care. The aim of this study was to examine if patients exposed to the intervention differed in their healthcare utilization compared with contemporaneous controls in the same time frame.

Methods: We used a PRE- and DURING-intervention population cohort comparison study design to estimate the effects of the iPEHOC intervention on the difference in difference (DID) for relative rates (RR) for emergency department (ED) visits, hospitalizations, psychosocial oncology (PSO), palliative care visits, and prescription rates for opioids and antidepressants compared with controls.

Results: A small significantly lower Difference in Difference (DID) (- 0.223) in the RR for ED visits was noted for the intervention compared with controls over time (0.947, CI 0.900-0.996); and a DID (- 0.0329) for patients meeting ESAS symptom thresholds (0.927, CI 0.869-0.990). A lower DID in palliative care visits (- 0.0097), psychosocial oncology visits (- 0.0248), antidepressant prescriptions (- 0.0260) and an increase in opioid prescriptions (0.0456) in the exposed population compared with controls was also noted. A similar pattern was shown for ESAS as a secondary exposure variable.

Conclusion: Facilitating uptake of PROs data may impact healthcare utilization but requires examination in larger scale "real-world" trials.
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http://dx.doi.org/10.1007/s00520-020-05313-3DOI Listing
October 2020

Does early palliative identification improve the use of palliative care services?

PLoS One 2020 31;15(1):e0226597. Epub 2020 Jan 31.

Odette Cancer Centre, Toronto, Ontario, Canada.

Purpose: To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based care services.

Methods: Between 2014 and 2017, physicians from eight sites were encouraged to systematically identify patients who were likely to die within one year and would were thought to benefit from early palliative care. Patients in the INTEGRATE Intervention Group were 1:1 matched to controls selected from provincial healthcare administrative data using propensity score-matching. The use of palliative care, community-based care services (home care, physician home visit, and outpatient opioid use) and acute care (emergency department, hospitalization) was each evaluated within one year after the date of identification. The hazard ratio (HR) in the Intervention Group was calculated for each outcome.

Results: Of the 1,185 patients in the Intervention Group, 951 (80.3%) used palliative care services during follow-up, compared to 739 (62.4%) among 1,185 patients in the Control Group [HR of 1.69 (95% CI 1.56 to 1.82)]. The Intervention Group also had higher proportions of patients who used home care [81.4% vs. 55.2%; HR 2.07 (95% CI 1.89 to 2.27)], had physician home visits [35.5% vs. 23.7%; HR 1.63 (95% CI 1.46 to 1.92)] or had increased outpatient opioid use [64.3% vs. 52.1%); HR 1.43 (95% CI 1.30 to 1.57]. The Intervention Group was also more likely to have a hospitalization that was not primarily focused on palliative care (1.42 (95% CI 1.28 to 1.58)) and an unplanned emergency department visit for non-palliative care purpose (1.47 (95% CI 1.32 to 1.64)).

Conclusion: Physicians actively identifying patients who would benefit from palliative care resulted in increased use of palliative and community-based care services, but also increased use of acute care services.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226597PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994244PMC
April 2020

Operationalizing Outpatient Palliative Care Referral Criteria in Lung Cancer Patients: A Population-Based Cohort Study Using Health Administrative Data.

J Palliat Med 2020 05 16;23(5):670-677. Epub 2020 Jan 16.

Division of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.

Early referral of cancer patients for palliative care significantly improves the quality of life. It is not clear which patients can benefit from an early referral, and when the referral should occur. A Delphi Panel study proposed 11 major criteria for an outpatient palliative care referral. To operationalize major Delphi criteria in a cohort of lung cancer patients, using a prospective approach, by linking health administrative data. Population-based observational cohort study. The study population comprised 38,851 cases of lung cancer in the Ontario Cancer Registry, diagnosed from January 1, 2012, to December 31, 2016. We operationalized 6 of the 11 major criteria (4 diagnosis or prognosis based and 2 symptom based). Patients were considered eligible (index event) for palliative care if they qualified for any criterion. Among eligible patients, we identified those who received palliative care. Twenty-eight thousand one hundred sixty-four patients were eligible for palliative care by qualifying for either the diagnosis- or prognosis-based criteria ( = 21,036, 76.5%), or for symptom-based criteria ( = 7128, 23.5%). A total of 23,199 (82.4%) patients received palliative care. The median time from palliative care eligibility to the receipt of first palliative care or death or maximum study follow-up was 56 days (range = 17-348). We operationalized six major criteria that identified the majority of lung cancer patients who were eligible for palliative care. Most eligible patients received the palliative care before death. Future research is warranted to test these criteria in other cancer populations.
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http://dx.doi.org/10.1089/jpm.2019.0515DOI Listing
May 2020

High-Cost Patients and Preventable Spending: A Population-Based Study.

J Natl Compr Canc Netw 2020 01;18(1):23-31

Cancer Care Ontario, Toronto, Ontario, Canada.

Background: Although high-cost (HC) patients make up a small proportion of patients, they account for most health system costs. However, little is known about HC patients with cancer or whether some of their care could potentially be prevented. This analysis sought to characterize HC patients with cancer and quantify the costs of preventable acute care (emergency department visits and inpatient hospitalizations).

Methods: This analysis examined a population-based sample of all HC patients in Ontario in 2013. HC patients were defined as those above the 90th percentile of the cost distribution; all other patients were defined as non-high-cost (NHC). Patients with cancer were identified through the Ontario Cancer Registry. Sociodemographic and clinical characteristics were examined and the costs of preventable acute care for both groups by category of visit/condition were estimated using validated algorithms.

Results: Compared with NHC patients with cancer (n=369,422), HC patients with cancer (n=187,770) were older (mean age 70 vs 65 years), more likely to live in low-income neighborhoods (19% vs 16%), sicker, and more likely to live in long-term care homes (8% vs 0%). Although most patients from both cohorts tended to be diagnosed with breast, prostate, or colorectal cancer, those with multiple myeloma or pancreatic or liver cancers were overrepresented among the HC group. Moreover, HC patients were more likely to have advanced cancer at diagnosis and be in the initial or terminal phase of treatment compared with NHC patients. Among HC patients with cancer, 9% of spending stemmed from potentially preventable/avoidable acute care, whereas for NHC patients, this spending was approximately 30%.

Conclusions: HC patients with cancer are a unique subpopulation. Given the type of care they receive, there seems to be limited scope to prevent acute care spending among this patient group. To reduce costs, other strategies, such as making hospital care more efficient and generating less costly encounters involving chemotherapy, should be explored.
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http://dx.doi.org/10.6004/jnccn.2019.7342DOI Listing
January 2020

Value assessment of oncology drugs using a weighted criterion-based approach.

Cancer 2020 04 20;126(7):1530-1540. Epub 2019 Dec 20.

Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Background: Globally, the rising cost of anticancer therapy has motivated efforts to quantify the overall value of new cancer treatments. Multicriteria decision analysis offers a novel approach to incorporate multiple criteria and perspectives into value assessment.

Methods: The authors recruited a diverse, multistakeholder group who identified and weighted key criteria to establish the drug assessment framework (DAF). Construct validity assessed the degree to which DAF scores were associated with past pan-Canadian Oncology Drug Review (pCODR) funding recommendations and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS; version 1.1) scores.

Results: The final DAF included 10 criteria: overall survival, progression-free survival, response rate, quality of life, toxicity, unmet need, equity, feasibility, disease severity, and caregiver well-being. The first 5 clinical benefit criteria represent approximately 64% of the total weight. DAF scores ranged from 0 to 300, reflecting both the expected impact of the drug and the quality of supporting evidence. When the DAF was applied to the last 60 drugs (with reviewers blinded) reviewed by pCODR (2015-2018), those drugs with positive pCODR funding recommendations were found to have higher DAF scores compared with drugs not recommended (103 vs 63; Student t test P = .0007). DAF clinical benefit criteria mildly correlated with ESMO-MCBS scores (correlation coefficient, 0.33; 95% CI, 0.009-0.59). Sensitivity analyses that varied the criteria scores did not change the results.

Conclusions: Using a structured and explicit approach, a criterion-based valuation framework was designed to provide a transparent and consistent method with which to value and prioritize cancer drugs to facilitate the delivery of affordable cancer care.
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http://dx.doi.org/10.1002/cncr.32639DOI Listing
April 2020

Economic impacts of care by high-volume providers for non-curative esophagogastric cancer: a population-based analysis.

Gastric Cancer 2020 05 13;23(3):373-381. Epub 2019 Dec 13.

Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075, Bayview Avenue, T2-063, Toronto, ON, M4N 3M5, Canada.

Background: Esophagogastric cancer (EGC) is one of the deadliest and costliest malignancies to treat. Care by high-volume providers can provide better outcomes for patients with EGC. Cost implications of volume-based cancer care are unclear. We examined the cost-effectiveness of care by high-volume medical oncology providers for non-curative management of EGC.

Methods: We conducted a population-based cohort study of non-curative EGC over 2005-2017 by linking administrative datasets. High-volume was defined as ≥ 11 patients/provider/year. Healthcare costs ($USD/patient/month-survived) were computed from diagnosis to death or end of follow-up from the perspective of the healthcare system. Multivariable quantile regression examined the association between care by high-volume providers and costs. Sensitivity analyses were conducted by varying costing horizons and high-volume definitions.

Results: Among 7011 non-curative EGC patients, median overall survival was superior with care by high-volume providers with 7.0 (IQR 3.3-13.3) compared to 5.9 (IQR 2.6-12.1) months (p < 0.001) for low-volume providers. Median costs/patient/month-lived were lower for high-volume providers ($5518 vs. $5911; p < 0.001), owing to lower inpatient acute care costs, despite higher medication-associated and radiotherapy costs. Care by high-volume providers was independently associated with a reduction of $599 per patient/month-lived (95% confidence interval - 966 to - 331) compared to low-volume providers. The incremental cost-effectiveness ratio was - 393. Care by high-volume providers remained the dominant strategy when varying the costing horizon and the high-volume definition.

Conclusion: Care by high-volume providers for non-curative EGC is associated with superior survival and lower healthcare costs, indicating a dominant strategy that may provide an opportunity to improve cost-effectiveness of care delivery.
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http://dx.doi.org/10.1007/s10120-019-01031-wDOI Listing
May 2020

Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis.

Gastric Cancer 2020 03 18;23(2):300-309. Epub 2019 Oct 18.

Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, 2075 Bayview avenue, T2-063, Toronto, ON, M4N 3M5, Canada.

Background: While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume.

Methods: We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS.

Results: 7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93).

Conclusions: Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.
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http://dx.doi.org/10.1007/s10120-019-01012-zDOI Listing
March 2020