乌鸦传媒

Cancer survivorship includes multiple phases of recovery, requiring different aspects of care for the surveillance and prevention of recurrent cancer and the management of the long-term effects of cancer therapy. This is not only grossly under-investigated, but also particularly burdensome and challenging in the vulnerable population of elderly patients, who have significantly more comorbidities, placing them at higher risk during this phase.

Indeed, this population has a higher risk of progression or relapse, development of secondary cancers, and lasting physical symptoms or chronic toxicity from cancer treatment. To this end, Arjun Gupta et al. investigated "healthcare contact days," including ambulatory and institutional care over the period of 1 year, in cancer survivors older than age 65. This group reported their findings in quantifying and evaluating key factors associated with the time spent utilizing healthcare in elderly cancer survivors.

As noted in , of the 1,168 adults identified in the United States in 2019 in this retrospective study, an average of 28 healthcare contact days were consumed over the period of a year, which was reported to be 1.5 times the average for this population and comparable with the amount of contact days in elderly adults with multiple morbidities or frailty.

A vast majority of these days were spent in the ambulatory setting, with patients often receiving only a single type of service on an ambulatory contact day; indeed, 65% of these services were not coupled with a clinician visit on the same day. Contact days with oncologists were only about 3.7% of the total contact days, whereas primary care (4.7%) and non-oncology specialists (9.4%) contact days were far higher.

Key associations linked to greater contact days were: younger age, lower income, more comorbidities, poor self-rated health, and a tendency to "go to doctor as soon as feel bad." The type of cancer also influenced contact day utilization, with lung cancer and leukemia being the highest.

About 20% of patients in the study reported poor health or having difficulty getting to the doctor's office, both of which resulted in higher contact days. Alarmingly, a majority of patients in this analysis had more than 5 chronic conditions, and over 30% of the studied population reported living alone, with nearly 29% reporting functional impairment.

There were several key limitations. In addition to being a retrospective review of a database confined to the United States over the period of only 1 year in 2019, the population was predominantly Caucasian and metropolitan, with very few patients at the federal poverty level socioeconomically. Patients with end-stage renal disease were excluded, and another significant exclusion was the use of virtual care (presumably including telemedicine and messaging via EHR portals) and home care, both of which are fundamental means of delivering healthcare, especially in the modern/post-COVID era, including to geographically demarginalized or functionally impaired populations that rely on them.

Of the six cancers in the inclusion criteria, the majority of patients studied had either breast or prostate cancer. There was an allowance for ongoing chemotherapy and radiation -- presumably maintenance or adjuvant therapies, although this calls into question whether some of the patients had an ongoing acute or chronic diagnosis, rather than being classified as survivors. Moreover, there was no effort to conduct subgroup analyses by type of prior cancer treatment received, which would likely provide important context on the future risk-adjusted and appropriately prioritized or escalated need for healthcare.

Though defining and understanding the factors for healthcare contact days in survivorship are important questions to ask, we must also avoid the overly simplistic and fundamental mistake of thinking that reducing an arbitrary measure leads to better outcomes. For example, think about the assumptions and nuances we concede to in the now-standard 3-day hospital admission or penalties for re-admission rates in sick patients. Indeed, providing appropriate care for the appropriate situation in context is essential. To this end, I was pleased to read the authors' attempt to explain their important limitation of quantifying the nuanced differences between appropriate versus inappropriate overuse or underuse of healthcare which could have occurred in this population.

For example, inappropriate underuse could be present and most concerning for the underrepresented populations in this study, including those in non-metropolitan, rural areas, or in certain ethnicities including the, as characterized in the study, American Indian, Asian, and Hispanic populations, who had fewer reported contact days in the analysis. Conversely, there could also be non-cancer-symptom-based or even "fear-based" overuse, which could lead to unnecessary testing or visits.

Another example of this logic is in avoiding the simplistic assumption that all medical care can take place in 1 day. Though coupling of ambulatory services is ideal when possible in vulnerable populations, we know that particularly in cancer care, there are circumstances in which complex diagnostic imaging, pathology stains, genomic testing, or laboratory testing must be performed well in advance for allowance of these complex studies to be appropriately reviewed by the time of the clinical visit to provide a meaningful review of the objective clinical data to guide such a visit during the survivorship phase.

Overall, this paper reported important findings on a grossly under-investigated topic, creating a platform on which future studies can expand on further nuances. Indeed, it is important to identify demarginalized populations in cancer care and represent them more equitably in clinical trials.

In any case, beyond the realm of associations or correlations we make in important studies like this, the cause-and-effect gold standard of the scientific method calls for additional prospective studies to be performed in this space, with controlled, comparative interventional arms to impact this population in the most meaningful way.

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

As these analyses may be difficult to compare in aggregate, it would not be wrong to present case studies on specific circumstances and topics to bring light to various variables that are vital for effective cancer care in the elderly.

The concept of missed opportunities to couple ambulatory services and appointments could also be investigated further. In particular, the use of nurses and cancer navigators should be investigated as an intervention to improve upon not only appropriate utilization of healthcare, but also patients' experience, mental health, symptoms, and outcome.

Lastly, it would be intriguing to correlate whether increased ambulatory contact days or some other intervention would help reduce arguably the more risky institutional (i.e., emergency department, hospital, or nursing home) contact days.

Ultimately, to empower the period of survivorship in all patients, it is important to consider cancer care as a multidisciplinary disease and effort with a sufficient, prepared oncology workforce from the time of diagnosis through therapy and then eventually to post-treatment monitoring.

In my experience, although patients are often resilient to discuss and prepare themselves for the road ahead when it comes to the rendered treatment plan, they do not always anticipate or understand the challenges of the long-term journey beyond the acute phase of treatment during the phases of surveillance and survivorship, where they are most vulnerable to loss of follow-up or continuity and fragmented care.

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

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

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

Read the study here and an interview about it here.