Follow-Up Care Provider Preferences of Adolescent and Young Adult Cancer Survivors

PURPOSE

To explore the experiences and perspectives of adolescent and young adult (AYA) cancer survivors regarding patient-provider relationships and their preferences surrounding type of healthcare provider for follow-up care.

METHODS

We recruited AYA cancer survivors who were diagnosed between the ages of 15 and 39 using the Utah Cancer Registry. Twenty-eight survivors participated in six focus groups held between March and May of 2015 in Salt Lake City and St. George, Utah. This analysis focuses on how survivors' preferences about type of healthcare provider may influence their transition into, and utilization of, follow-up care.

RESULTS

On average, survivors were 6.3 (standard deviation = 1.7) years from their cancer diagnosis. A majority of survivors expressed a desire not to transition to a new provider and preferred continuing to see their oncologist for follow-up care. For these survivors, this was due to already having a close relationship with their oncologist and because they trusted their provider's knowledge about cancer and how to handle late effects. However, survivors placed emphasis on being comfortable with their healthcare provider, regardless of provider type.

CONCLUSIONS

Our findings demonstrate the importance of formalizing provider transitions and roles after cancer therapy to improve patient comfort with new providers. By understanding the complexities of the transition from active cancer treatment to follow-up care for AYA survivors, these findings can inform programs undertaking post-care educational activities to ensure a seamless transition into survivorship care. Survivorship care plans can facilitate these transitions and improve patient confidence in follow-up care.

Conditional survival of pediatric, adolescent, and young adult soft tissue sarcoma and bone tumor patients

BACKGROUND

Survival estimates for soft tissue sarcomas (STS) and malignant bone tumors (BT) diagnosed in pediatric, adolescent, and young adult patients are not easily available. We present survival estimates based on a patient having survived a defined period of time (conditional survival). Conditional survival estimates for the short-term were calculated for patients from diagnosis to the first five years after diagnosis and for patients surviving in the long-term (up to 20 years after diagnosis).

METHODS

We identified 703 patients who were diagnosed with a STS or BT at age ≤25 years from January 1, 1986 to December 31, 2012 at a large pediatric oncology center in Salt Lake City, Utah, United States. We obtained cancer type, age at diagnosis, primary site, and demographic data from medical records, and vital status through the National Death Index. Cancer stage was available for a subset of the cohort through the Utah Cancer Registry. Cox proportional hazards models, adjusted for age and sex, calculated survival estimates for all analyses.

RESULTS

Short-term survival improves over time for both sarcomas. Short-term survival for STS from diagnosis (Year 0) did not differ by sex, but short-term survival starting from 1-year post diagnosis was significantly worse for male patients (Survival probability 1-year post-diagnosis [SP1]:77% [95% CI:71-83]) than female patients (SP1:86% [81-92]). Survival for patients who were diagnosed at age ≤10 years (Survival probability at diagnosis [SP0]:85% [79-91]) compared to diagnosis at ages 16-25 years (SP0:67% [59-75]) was significantly better at all time-points from diagnosis to 5-years post-diagnosis. Survival for axial sites (SP0:69% [63-75]) compared to extremities (SP0:84% [79-90]) was significantly worse from diagnosis to 1-year post-diagnosis. Survival for axial BT (SP0: 64% [54-74] was significantly worse than BT in the extremities (SP0:73% [68-79]) from diagnosis to 3-years post diagnosis. Relapsed patients of both sarcoma types had significantly worse short-term survival than non-relapsed patients. Long-term survival for STS in this cohort is 65% at diagnosis, and improves to 86% 5-years post-diagnosis. BT survival improves from 51% at diagnosis to 78% at 5-years post-diagnosis.

CONCLUSION

Conditional survival for short- and long-term STS and BT improve as time from diagnosis increases. Short-term survival was significantly affected by patients' sex, age at diagnosis, cancer site, and relapse status.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Risk of hospitalization among survivors of childhood and adolescent acute lymphoblastic leukemia compared to siblings and a general population sample

BACKGROUND

Acute Lymphoblastic Leukemia (ALL) has a high survival rate, but cancer-related late effects in the early post-treatment years need documentation. Hospitalizations are an indicator of the burden of late effects. We identify rates and risk factors for hospitalization from five to ten years after diagnosis for childhood and adolescent ALL survivors compared to siblings and a matched population sample.

METHODS

176 ALL survivors were diagnosed at ≤22 years between 1998 and 2008 and treated at an Intermountain Healthcare facility. The Utah Population Database identified siblings, an age- and sex-matched sample of the Utah population, and statewide inpatient hospital discharges. Sex- and birth year-adjusted Poisson models with Generalized Estimating Equations and robust standard errors calculated rates and rate ratios. Cox proportional hazards models identified demographic and clinical risk factors for hospitalizations among survivors.

RESULTS

Hospitalization rates for survivors (Rate:3.76, 95% CI=2.22-6.36) were higher than siblings (Rate:2.69, 95% CI=1.01-7.18) and the population sample (Rate:1.87, 95% CI=1.13-3.09). Compared to siblings and population comparisons, rate ratios (RR) were significantly higher for survivors diagnosed between age 6 and 22 years (RR:2.87, 95% CI=1.03-7.97 vs siblings; RR:2.66, 95% CI=1.17-6.04 vs population comparisons). Rate ratios for diagnosis between 2004 and 2008 were significantly higher compared to the population sample (RR:4.29, 95% CI=1.49, 12.32), but not siblings (RR:2.73, 95% CI=0.54, 13.68). Survivors originally diagnosed with high-risk ALL did not have a significantly higher risk than siblings or population comparators. However, high-risk ALL survivors (Hazard ratio [HR]:3.36, 95% CI=1.33-8.45) and survivors diagnosed from 2004 to 2008 (HR:9.48, 95% CI=1.93-46.59) had the highest risk compared to their survivor counterparts.

CONCLUSIONS

Five to ten years after diagnosis is a sensitive time period for hospitalizations in the ALL population. Survivors of childhood ALL require better long-term surveillance.

Abstract B19: Pediatric Cancer Late Effects Clinic Patients in Utah: Potential Barriers to Care

Background: Cancer late effects clinics are important to manage health complications experienced by cancer survivors, but little is known about potential barriers to attendance in rural states where many patients live far away from cancer centers. We identify demographic, clinical and residency factors associated with clinic attendance at the only pediatric cancer late effects clinic in Utah.

Methods: Medical records identified survivors diagnosed with cancer at age ≤25 years from 1986-2011 who currently reside in Utah. We linked records to the late effects clinic patient registry, available from 2010 to present. Participants were geocoded using their most recent residential zip code according to medical and driver's license records. The Euclidean distance between the clinic and the centroid of each zip code were calculated. Participants were classified into median income brackets based on the same zip code information. Log-linear models identified associations between attendance and the demographic and clinical factors. Generalized estimating equations were used in analyses for zip-code level residential distance and income with attendance.

Results: Of 1,935 survivors, only 10% had ≥1 clinic visit. Attendance is associated with leukemia/lymphoma diagnosis (odds ratio [OR]=1.65; 95% confidence interval [CI]=1.14-2.39 vs. other solid tumors) and current age between 19-30 years (OR=3.01; 95% CI=1.33-6.79 vs. ≥30 years). Hispanic ethnicity was not associated with late effects clinic attendance (OR=0.94; 95% CI =0.47-1.87 vs Non-Hispanic). Living in a zip code with a residential distance of less than 20 miles (OR=1.37, 95% CI=0.73-2.58 vs. ≥60 miles), and living in zip codes with median income between $60,000 and $70,000 (OR=1.45, 95% CI=0.67-3.11 vs. >$50,000/year) showed positive, non-significant associations with attendance.

Conclusions: Late effects clinics are not widely attended by childhood and adolescent cancer survivors in Utah. Current age and previous cancer diagnosis are associated with attendance. Area of residence and income show possible associations with clinic attendance, although more investigation is needed to examine how these access-related factors influence attendance. Outreach efforts may be needed to connect cancer survivors with late effects clinics. Further investigation is needed to identify potential economic and geographic barriers to care.

Citation Format: Judy Y. Ou, Rochelle R. Smits-Seemann, Jennifer A. Wright, Anne C. Kirchhoff. Pediatric Cancer Late Effects Clinic Patients in Utah: Potential Barriers to Care. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B19.

Adolescent and Young Adult Cancer Survivors' Valuation of Post-Treatment Recommended Care

PURPOSE

Examine whether survivors of adolescent and young adult (AYA) cancer value recommended post-treatment care using focus groups and a willingness to pay (WTP) survey. WTP, a measure of value, indicates the dollar amount individuals are willing to pay to use a service.

METHODS

Participants were recruited through the Utah Cancer Registry. N = 28 survivors diagnosed with cancer at ages 15-39 and currently aged ≥18 participated in focus groups, and N = 4 in phone interviews (participation rate = 50%). All participants responded to a demographic survey and WTP questions based on one-time and monthly payments for annual visits. Focus group participants responded to an open-ended question on the value of follow-up care. Interval regressions identified factors associated with WTP. Qualitative analysis summarized themes for the open-ended question.

RESULTS

Focus group participants reported valuing follow-up care as it brings peace of mind and helps them manage their health. Yet, 38% reported not having a cancer-related visit in the previous year. Only 27% and 43% of survivors agreed to pay any one-time and monthly payments, respectively. The monthly payment mean WTP was $41 (95% confidence interval [CI]: 31-84), equating to $494 annually, which is greater than the mean WTP for one-time payment ($362, 95% CI: 293-432, p < 0.001), suggesting that survivors may prefer monthly payments. Several factors, including being female and in better health, predicted higher WTP.

CONCLUSION

Many AYA cancer survivors report not visiting their doctors annually for post-treatment care despite verbally valuing care. Models that demonstrate high quality and distribute costs over time should be evaluated to encourage survivors to receive recommended care.

Barriers to follow-up care among survivors of adolescent and young adult cancer

PURPOSE

Though the need for risk-based follow-up care for survivors of adolescent and young adult (AYA) cancer has been documented, survivors often report forgoing recommended care due to cost. We sought to understand whether additional barriers to follow-up care exist for AYA survivors.

METHODS

We recruited survivors who were diagnosed with cancer between the ages of 15 and 39 using the Utah Cancer Registry (UCR). Overall, 28 survivors participated in 6 focus groups held between March and May 2015 in Salt Lake City and St. George, UT. Focus group discussions focused on the reasons survivors may or may not attend recommended medical visits after completing therapy.

RESULTS

Survivors reported myriad barriers to follow-up medical visits, including lack of clear provider recommendation, fear of recurrent cancer diagnosis, wishing to move on with life, competing life responsibilities due to work and children, and not perceiving the need for a visit due to lack of symptoms.

CONCLUSIONS

Though cost likely plays a major part in follow-up care adherence for survivors of AYA cancer, in our focus groups, participants indicated there were many other psychosocial and logistic barriers to care. Such factors play an important role in the day-to-day lives of survivors and are critical in medical decision-making.

IMPLICATIONS FOR CANCER SURVIVORS

Several factors impede follow-up care adherence for survivors of AYA cancer that are amenable to interventions, including clearer provider recommendations, flexible appointment times, and childcare availability in clinics.

A Qualitative Inquiry of Childhood and Adolescent Cancer Survivors' Perspectives of Independence

PURPOSE

This report examines facilitators and barriers to independence for a sample of survivors of childhood and adolescent cancer.

METHODS

We conducted 53 semistructured, in-depth interviews with adult survivors of cancer diagnosed at ages 0-20 years. Researchers qualitatively coded themes to reflect responses to the question inquiring about how cancer may have affected survivors' independence from their parents.

RESULTS

Among the 21 survivors who reported that cancer affected their independence, themes included challenges and motivators to independence following cancer. Challenges to independence included overprotection by parents, financial dependence, problems in healthcare decision-making, and emotional dependence. Motivators included self-confidence, desire for independence, parental support, and inadequate family support.

CONCLUSION

Supportive care for survivors of childhood and adolescent cancers should include services to help them in their journey toward developmental independence.

ReCAP: Gaps in Insurance Coverage for Pediatric Patients With Acute Lymphoblastic Leukemia

QUESTION ASKED:

We sought to determine the likelihood that pediatric and adolescent acute lymphoblastic leukemia (ALL) patients experience a gap in health insurance coverage in the first 2 years of therapy.

SUMMARY ANSWER:

We found that 12% of patients with ALL in our sample who had insurance at diagnosis experienced a gap in insurance coverage during the first 2 years of therapy; that is, they had one or more clinic encounter at which they did not have insurance. Patients with public insurance at diagnosis were more likely to experience an insurance gap than those with private insurance at diagnosis, and those diagnosed in more recent years were less likely to experience a gap.

METHODS/APPROACH:

We determined insurance status at all clinic encounters at a tertiary children’s hospital within 2 years of diagnosis for patients diagnosed with ALL between 1998 and 2010, and calculated the odds of a gap occurring on the basis of demographic and diagnostic variables.

BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:

Our assessment is from years before the roll-out of key Patient Protection and Affordable Care Act provisions, which should improve insurance coverage for pediatric and adolescent patients with ALL. In addition, we lacked information on patient or caregiver socioeconomic status, which may be important for explaining insurance gaps. Finally, our assessment is based on a single institution.

REAL-LIFE IMPLICATIONS:

Gaps in health insurance may exacerbate the financial and emotional burden associated with pediatric and adolescent cancer. Understanding the likelihood that these gaps will occur, as well as predictors of insurance gaps, will allow social workers and other providers to help families manage anticipated changes in insurance, with the goal of reducing unnecessary burden. [Figure: see text]