Health care needs, primary prevention & quality of life ... · Comparison group p-value (n=250)...

Prof. Siegal Sadetzki (MD, MPH) Cancer & Radiation Epidemiology Unit, Gertner Institute

CANCER SURVIVORSHIP Israel Cancer Association & Councils for Health

February 6th, 2017

Dr. Lori Mandelzweig, Mrs. Angela Chetrit, Mrs. Tova Amitai, Mrs. Bernice Oberman, Dr. Nava Siegelmann Danieli, Dr. Barbara Silverman

Health care needs, primary prevention & quality of life among long term breast cancer survivors in Israel

https://www.google.co.il/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiS37_0rufRAhWEsxQKHfNHC-kQjRwIBw&url=https://www.pinterest.com/fredahalllee/im-a-breast-cancer-survivor/&psig=AFQjCNHv0_78zQUrSvWi3LZgH9p4uIQ6Zg&ust=1485779675871557

Estimated number of cancer survivors in the US

DeSantis C et al; Cancer J Clinicians (2014)

IOM 2006

Cancer care trajectory

Long term follow-up of BC survivors - Background

Significant improvements in diagnosis and treatment of BC have resulted in an increase in survival rates of this population.

This has been observed worldwide as well as in Israel

Consequentially, efforts should be directed to characterize the specific needs of this population:

Surveillance for recurrence

Attention for late & long-term effects of cancer treatments

Surveillance for preventive care for co-morbidity

Assessment of health services needs

Evaluation of informational & emotional needs

Mandelzweig L et al, Identification of health care needs of long-term breast cancer survivors among Israeli women. Support Care Cancer (2016) 24:737–746

There is a concern that due to the focus on issues related to cancer & the lack of clarity concerning the roles of oncologists & primary care providers,

cancer survivors may not be receiving the appropriate care and attention needed to maintain their health & well being

Sadetzki S et al, long-term breast cancer survivors (sent for publication)

To assess: Use of health services

Morbidity status

Compliance rates of selected primary & secondary prevention practices

Quality of life

among long-term BC survivors in Israel

Long term follow-up of BC survivors Background

Mandelzweig L et al, Support Care Cancer (2016)

AIMS


Methods

Study design: Matched “case-control”

Study population:

Inclusion criteria: Living in central Israel

Members of Maccabi healthcare services (the 2nd largest Israeli HMO)

CASES (n=250) CONTROLS (n=250)

Long term BC survivors (diagnosed with BC between 1999-2003 and had no evidence of the disease after 8-12 years)

Women with no history of any cancer

The controls were individually matched to cases by age (+2 years) & area of residence

Health care needs, primary prevention & quality of life among long-term Breast Cancer (BC) survivors


Data collection Face to face interviews

Structured questionnaire including:

Satisfaction with health care services

Socio-demographic items

Health promotion by the family physician

Lifestyle habits

Participation in primary & secondary prevention procedures

Morbidity

Depression and anxiety Anthropometric characteristics

Quality of life assessment

Health care services use



* Selected data were collected for 2 periods: 1 year prior to BC diagnosis & at time of interview


Description of recruitment of the study population

RESULTS Demographic & selected life style characteristics of the study groups

p-value Comparison group

(n=250)

Cases

(n=250)

Category Characteristics

% %

0.7 65.3+10.5 65.9+10.3 Mean+SD Age at interview

0.9 38.9 36.9 Primary and high Education

20.2 21.3 Post high

40.9 41.8 University

0.2 29.6 23.6 Higher than average income Income

19.2 19.6 Similar to average income

22.0 21.2 Lower than average income

12.8 17.6 Much lower than average income

16.4 18.0 Unknown

0.4 46.4 49.6 White collar worker Occupation

46.8 40.4 Blue collar worker

5.2 6.8 Housewife

1.6 3.2 Unknown

0.3 59.4 61.6 Secular Level of Religiosity

30.9 25.6 Traditional

9.6 12.8 Observant/Ultra-Orthodox

0.04 11.6 6.8 0 No. of children

38.4 48.0 1-2

50.0 45.2 3+

Description of the study population by socioeconomic characteristics & study group



Description of the study population by smoking characteristics & study group

P value Comparison

group (n=250)

Cases

(n=250)


% %

0.04a 64.8 55.6 Never smoked Smoking

habits 35.2 44.4 Ever smoked

0.10b 13.2 15.6 Current smoker

22.0 28.8 Past smoker

15.2 22.0 Stopped smoking

before BC diagnosisc

6.8 6.8 Stopped smoking after

BC diagnosisc

0.3 21.0+7.3 20.0+5.5 Age at start of

smoking (Mean+SD)

0.6 23.7+18.6 25.4+20.8 Pack years

(Mean+SD) a P-value for Ever / Never; b P-value for Never / Current / Past; c For controls the date of diagnosis of their

matched case was used


(Sadetzki S et al, long-term breast cancer survivors – sent for publication)

Description of the study population by smoking characteristics & study group

P value Comparison

group (n=250)

Cases

(n=250)


% %

0.04a 64.8 55.6 Never smoked Smoking

habits 35.2 44.4 Ever smoked

0.10b 13.2 15.6 Current smoker

22.0 28.8 Past smoker

15.2 22.0 Stopped smoking

before BC diagnosisc

6.8 6.8 Stopped smoking after

BC diagnosisc

0.3 21.0+7.3 20.0+5.5 Age at start of

smoking (Mean+SD)

0.6 23.7+18.6 25.4+20.8 Pack years

(Mean+SD) a P-value for Ever / Never; b P-value for Never / Current / Past; c For controls the date of diagnosis of their

matched case was used



More cases ever smoked but cessation of smoking was not related to BC diagnosis

Description of the study population by Body Mass Index & study group

* For controls the date of diagnosis of their matched case was used

Current BMI BMI in the year preceding diagnosis of breast cancer*

Body Mass Index (Kg/m2)

P

Comparison group (n=250)

Cases (n=250)

P Comparison group (n=250)

Cases (n=250)

% % % %

0.9

1.6 2.0

0.7

4.1 3.4 <18.5

(Underweight)

43.0 43.7 58.9 60.3 18.5-24.9

(Normal weight)

39.0 37.1 25.1 27.4 25.0-29.9

(Overweight)

16.5 17.1 11.9 9.0 30+

(Obese)



No differences in the distribution of BMI were seen between the groups. However, increase in overweight

& obesity with age was seen in both groups

Description of the study population by Leisure

time physical activity & study group


(Sadetzki et al, long-term breast cancer survivors - sent for publication)

Physical activity at time of

interview

Physical activity in the year

preceding diagnosis of BC* Leisure time physical activity P Comparison

group (n=250)

Cases

(n=250) P Comparison

group (n=250)

Cases

(n=250)

% % % %

0.3

22.0 24.8

0.05

34.4 34.0 No physical activity

24.0 28.4 17.2 26.8 Light physical activity

(Tertile 1)

28.0 21.2 23.6 20.0 Moderate physical

activity (Tertile 2)

26.0 25.6 24.8 19.2 Strenuous physical



33% 5%

Description of the study population by Leisure

time physical activity & study group



Physical activity at time of

interview

Physical activity in the year

preceding diagnosis of BC* Leisure time physical activity P Comparison

group (n=250)

Cases

(n=250) P Comparison

group (n=250)

Cases

(n=250)

% % % %

0.3

22.0 24.8

0.05

34.4 34.0 No physical activity

24.0 28.4 17.2 26.8 Light physical activity

(Tertile 1)

28.0 21.2 23.6 20.0 Moderate physical


26.0 25.6 24.8 19.2 Strenuous physical



In both groups, an increase in practicing PA at time of interview was noted but this improvement was much

higher in cases (33% vs. 5%)

33% 5%

HEALTH SERVICES USE

http://www.google.co.il/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjf-O78lfHRAhXFWBoKHfrSCKEQjRwIBw&url=http://www.highpoint.edu/welcomeweek/health-services/&bvm=bv.146073913,d.d2s&psig=AFQjCNEDzBgBrinhzDi8H-Ep_EuR_hrEEg&ust=1486115637881099

Frequency of Annual Medical Consultation by Study Group & Type of Service*

95%CI Odds Ratio

Controls (n=250)

Cases (n=250)

Type of service

% N % N

0.88-4.09 1.90 90.8 227 94.4 236 General Practitioner

1.78-5.49 3.13 76.8 192 90.4 226 Specialist

0.88-2.72 1.53 10.4 26 14.4 36 Psychological support**

(38.1) (56.8) Privately

0.99-2.63 1.62 11.6 29 18.0 45 Contact with ambulance or emergency health service center

0.89-2.46 1.48 12.4 31 17.2 43 Visit to Emergency Room

0.98-2.03 1.41 33.9 81 40.7 101 Hospitalizations * Data on visits to physicians & other health services refer to at least one visit in the last year,

while hospitalizations refer to the 5 year period preceding the interview ** 30% in both groups replied that they would go for psychological support if the service was free of

charge


Number & duration of visits to the family physician & to specialists by study group

Cases (n=250) Controls (n=250) OR* 95% CI

FAMILY PHYSICIAN

Total consultations during

the past year

945 813

Number of visits (Mean+SD) 3.78+2.42 3.25+2.48 1.48 1.07-2.06

Number of visits by duration (Mean+SD)

<10 minutes 1.81+2.45 1.87+2.23 0.78 0.57-1.09

10 minutes + 1.92+2.29 1.37+2.31 1.69 1.21-2.37

SPECIALISTS

Total consultations during

the past year

1143 854

Number of visits (Mean+SD) 4.57+4.25 3.42+3.59 1.72 1.23-2.40

Number of visits by duration (Mean+SD)

<10 minutes 0.61+1.09 0.69+1.31 0.96 0.67-1.38

10 minutes + 2.27+1.90 1.57+1.69 2.13 1.55-2.93 * Risk of cases to be in higher quartile of health service use compared to controls – Derived from ordered GEE models


Reasons for visits to the family physician

Reasons for visits to specialists

P=0.002

P=0.09

P=0.05

P<0.001

P=0.06

*

*

*

*

* *

*Not significant

While 80% of cases defined the family physician as their main treating physician, 50% of them still considered their oncologist responsible for cancer follow-up

Prevalence of reported diseases by Study Group

Disease

Cases (n=250)

Controls (n=250)

OR 95%CI

N % N %

Diabetes 37 14.8 35 14.0 1.07 0.64-1.77

Hypertension 74 29.6 79 31.6 0.89 0.59-1.40

Heart diseases 28 11.2 23 9.2 1.36 0.81-2.31

Lung diseases 22 8.8 21 8.4 1.05 0.56-1.97

Digestive diseases 43 17.2 51 20.4 0.82 0.53-1.27

Urinary tract diseases 25 10.0 9 3.6 2.78 1.30-5.95

Blood diseases 15 6.0 15 6.0 1.00 0.46-2.16

Neurological diseases 19 7.6 13 5.2 1.50 0.72-3.11

Joint diseases 31 12.4 28 11.2 1.12 0.65-1.92

Thyroid diseases 59 23.6 64 25.6 0.88 0.58-1.36

Genetic diseases 4 1.6 7 2.8 0.62 0.22-1.77

Eye diseases 19 7.6 10 4.0 1.90 0.88-4.09

Muscle diseases 22 8.8 20 8.0 1.05 0.57-1.94

Gynecological diseases 12 4.8 12 4.8 1.00 0.43-2.31

Dyslipidemia 15 6.0 30 12 0.42 0.21-0.85

Prevalence of reported diseases by Study Group

Disease

Cases (n=250)

Controls (n=250)

OR 95%CI

N % N %

Diabetes 37 14.8 35 14.0 1.07 0.64-1.77

Hypertension 74 29.6 79 31.6 0.89 0.59-1.40

Heart diseases 28 11.2 23 9.2 1.36 0.81-2.31

Lung diseases 22 8.8 21 8.4 1.05 0.56-1.97

Digestive diseases 43 17.2 51 20.4 0.82 0.53-1.27

Urinary tract diseases 25 10.0 9 3.6 2.78 1.30-5.95

Blood diseases 15 6.0 15 6.0 1.00 0.46-2.16

Neurological diseases 19 7.6 13 5.2 1.50 0.72-3.11

Joint diseases 31 12.4 28 11.2 1.12 0.65-1.92

Thyroid diseases 59 23.6 64 25.6 0.88 0.58-1.36

Genetic diseases 4 1.6 7 2.8 0.62 0.22-1.77

Eye diseases 19 7.6 10 4.0 1.90 0.88-4.09

Muscle diseases 22 8.8 20 8.0 1.05 0.57-1.94

Gynecological diseases 12 4.8 12 4.8 1.00 0.43-2.31

Dyslipidemia 15 6.0 30 12 0.42 0.21-0.85

No differences in reported morbidity were seen between the study groups

COMPLIANCE TO PRIMARY & SECONDARY PREVENTIVE CARE

Women reporting undergoing screening procedures by study group (% & OR)

Procedures performed in

the last 5 years

Cases Comparison

group n % n % OR (95%CI) Adjusted b OR (95%CI)

Flu vaccine a 132 52.8 115 46.0 1.31 (0.92, 1.87) 1.42 (0.95, 2.13)

Blood Lipids 178 71.2 190 76.0 0.78 (0.52, 1.16)

Thyroid tests 144 57.6 153 61.2 0.86 (0.60, 1.23)

Occult bloods 124 49.6 123 49.2 1.02 (0.72, 1.44)

Colonoscopy 129 51.6 105 42.0 1.47 (1.03, 2.10) 1.48 (1.02, 2.13)

Bone Mineral Density Scan 198 79.2 156 62.4 2.29 (1.54, 3.42) 2.59 (1.69, 3.98)

Pap Smear test 151 60.4 143 57.2 1.14 (0.80, 1.63)

Gynecological examination 184 73.6 172 68.8 1.26 (0.86, 1.86)

Mammography 243 97.2 211 84.4 6.42 (2.81, 14.65) 7.71 (3.25, 18.3)

Breast US 228 91.2 134 53.6 8.97 (5.52, 15.17)

Manual breast examination a 200 80.0 103 41.2 5.71 (3.85, 8.57)

a Performed in the last year b Adjusted for age, education, level of religiosity, smoking, income & physical activity

(Sadetzki S et al, long-term breast cancer survivors - sent for publication)


QUALITY OF LIFE

http://www.google.co.il/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi7j6f9lvHRAhUL1RoKHY5UBpwQjRwIBw&url=http://actsofkindnesss.org/quality-of-life/&bvm=bv.146073913,d.d2s&psig=AFQjCNGuglR7zI_6_nLsHQdxmEovEDrC3w&ust=1486116663659795

Quality Of Life (QOF, SF-36) components: Examples

Physical functioning – Severe & minor physical limitations in lifting & carrying groceries, climbing stairs, walking moderate distances

Role functioning – Problems with work or other activities as a result of physical health

Bodily pain – Intensity of pain interfering with both work outside the home & housework

Social functioning- To what extent has physical health interfere with normal social activities with family, friends, neighbors

Mental health- Anxiety, depression, loss of behavioral or emotional control & psychological well being

Emotional health- Accomplishing less than desired, not attentive as usual

Vitality- Energy level & fatigue

General health- Getting sick, being healthier than others, expecting health to get worse, being in excellent health

Mean score of Quality Of Life components (SF36) by study group

0

10

20

30

40

50

60

70

80

90

100

Physicalfunctioning

Rolefunctioning

Bodily pain Socialfunctioning

Mentalhealth

Emotionalhealth

Vitality Generalhealth

Me

an s

core

QOL components

cases controls

P=0.004

P=0.047 P=0.007

P=0.3

P=0.2

P=0.047

P=0.03

P=0.02



Mean score of Quality Of Life summary indices (SF36) by study group

82

84

86

88

90

92

94

96

98

Physical component Mental component

Me

an s

core

QOL summary indices

cases controlsP=0.03

P=0.10



Summary & Conclusions Use of health services:

Cases made greater use of health services compared to an age-matched comparison group, expressed by more visits to family physicians & specialists, longer duration of visits, more requests for referrals, more frequent contact with emergency services, and hospitalizations.

The results of the study indicate a need to:

Shift the responsibility of the follow-up of BC survivors from the oncologist to the family physician

Improve the coordination between disciplines of oncology & community medicine for the medical care of BC survivors

Facilitate psychological support



Summary & Conclusions Prevention practices:

Higher performance rates of mammography & colonoscopy among BC survivors were observed, as well as a greater likelihood of receiving an influenza vaccine and undergoing a bone mineral density scan compared to controls.

The survivors adopted healthier lifestyles (smoking & PA), which were similar to those of women who never had cancer.

About 10 years after BC diagnosis, the survivors generally comply with primary & secondary prevention practices.

Quality Of Life:

Statistically significant differences between the groups were seen for physical functioning, role functioning, bodily pain, role functioning/ emotional, vitality, and general health.

A statistically significant difference was shown for the physical component but not for the mental component.



Health care needs, primary prevention & quality of life ... · Comparison group p-value (n=250)...

Documents

Transcript of Health care needs, primary prevention & quality of life ... · Comparison group p-value (n=250)...