US Physician Concordance with Update to Guidelines Classifying Carboplatin AUC ! 4 as Highly Emetogenic Chemotherapy

RM Navari, KJ Ruddy, TW LeBlanc, R Clark-Snow, RJ Wickham, G Binder, T Coberly, R Potluri, LM Schmerold, EJ Roeland

Author disclosure

• Consultant for Helsinn and Heron Therapeutics. Research study funding from Heron Therapeutics

Background & Objective

• MASCC, NCCN and ASCO antiemetic guidelines recently classified carboplatin AUC ≥4 as HEC– Recommend upfront triple prophylaxis

• (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone)

• NV among 10 toxicities deemed by CMS as “potentially avoidable acute care” and tracked in OP-35 measure1

• Objective: to assess – US physician concordance with the updated guidelines– consequences for avoidable post-chemotherapy acute care

1. Federal Register Volume 81, Number 135 (Thursday, July 14, 2016)]

Methodology• Data source: IBM Explorys electronic health records Oct. 2012 – Aug. 2018

§ Strengths• Current, detailed physician and patient longitudinal data

§ Limitations• Acute care may be underestimated (unavailable if occur at non-network sites)• Patient population is concentrated in the Midwest

• Analysis: – Evaluated carboplatin AUC >4 (using cycles >14 days), other chemo– Guideline concordance: triple prophylaxis at HEC initiation– Acute care (IP/ED) utilization <30 days post-chemo was compared by regimen– Avoidable acute care as defined by OP-35, CMS’ new oncology outcome measure

• Involving NV or any of eight other toxicities

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Patient characteristicsCarboplatin Other HECs Oxaliplatin Other non-HECs HEC/MEC Oral

Age, Mean (SD) 64 (12) 60 (13) 62 (12) 63 (15) 60 (14)

Female, n (%) 8,125 (70%) 9,827 (61%) 2,096 (43%) 33,353 (58%) 1,099 (54%)

Region, n (%)Midwest 7,773 (67%) 9,933 (62%) 3,089 (63%) 34,502 (60%) 1,431 (70%)

South 2,087 (18%) 3,362 (21%) 973 (20%) 12,066 (21%) 283 (14%)

West 1,467 (13%) 2,397 (15%) 727 (15%) 9,435 (16%) 275 (13%)

Cancer type, n (%)Breast 2,032 (18%) 5,217 (33%) 93 (2%) 5,105 (9%) 131 (6%)

Lung 4,185 (36%) 1,615 (10%) 112 (2%) 3,703 (6%) 173 (8%)

GI 1,095 (9%) 2,009 (13%) 4,601 (94%) 7,045 (12%) 74 (4%)

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Nausea/Vomiting is common in post-carboplatin acute care

3,152 carboplatin courses had acute care events (31% of 10,330 carboplatin courses administered in OP

setting)2,370 acute care events involved ≥1 of the 10 OP-35 toxicities

(75% of 3,152 total acute care events)

647 acute care events involved

nausea/vomiting (27% of 2,370 OP-35

acute care events)

Note: The area of each box is proportional to the percentage listed.

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Conclusions

• US upfront triple antiemetic prophylaxis grew only marginally for carboplatin AUC ≥ 4 since re-classification as HEC, perhaps due to:– low awareness of the guideline changes – low awareness of the post-carbo acute care rate involving CINV

• NV and related 30-day acute care event rates for carboplatin matched those for other HEC, validating the HEC classification

• More upfront triple prophylaxis is needed to reduce NV and NV-related avoidable acute care with carboplatin AUC ≥ 4