Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer

Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer

 

Daniella Febbraro*; Dr. Michela Febbraro, MD1; Dr. Mohammad Rassouli-Rashti, MD, PhD, FRCPC2,3; Dr. Silvana Spadafora, MD, FRCPC2,3

 

 

Corresponding author:

Daniella Febbraro

14 Highcrest Street

Sault Ste. Marie, Ontario

P6B 5V2

705-971-2637

daniella.febbraro@gmail.com

 

Contact Information:

Dr. Michela Febbraro mifebbraro@nosm.ca

Dr. Mohammad Rassouli-Rashti rassoulim@sah.on.ca

Dr. Silvana Spadafora spadaforas@sah.on.ca

 

Affiliations:

1955 Oliver Road,
Thunder Bay, Ontario
P7B 5E1

2Algoma District Cancer Program,
750 Great Northern Road,
Sault Ste. Marie, Ontario
P6B 0A8

3Northern Ontario School of Medicine,
935 Ramsey Lake Road,
Sudbury, Ontario
P3E 2C6


Abstract

Purpose: The Algoma District Cancer Program (ADCP), situated in Sault Ste. Marie, ON, services 125,000 individuals residing in an area of approximately 49,000 km2. Given the isolated environment, maintaining standards of care for prostate cancer patients can be challenging. Local referral processes were modified with new treatment guidelines and the addition of two medical oncologists. The objective was to analyze the impact of this new referral process on treatment of patients with prostate cancer at ADCP. Methods: A retrospective chart audit was conducted on all prostate cancer patients seen by an ADCP medical oncologist from July 2013 to February 16, 2016. Charts were analyzed for information including date of diagnosis, stage at time of referral, date of first consult, previous treatments, and dates of treatment. Patients were divided into two groups, medical oncology consult before and after January 1, 2014, to examine ADCP progress. Results: There were 101 prostate cancer patients seen by a medical oncologist at ADCP during the study; 16 with consults prior to and 85 with consults after January 1, 2014. The number of prostate cancer consults more than doubled between 2014 and 2015. More patients are now seen while asymptomatic; thereby increasing treatment modalities available. The number of lines of therapies used by medical oncologists went from 8 to 25 between the two patient groups. Conclusions: Since the arrival of new medical oncologists in July 2013, improvement in both referral processes and adherence to standard guidelines in the treatment of prostate cancer patients have occurred.

 

Key words: prostate cancer, referral processes, chart review, medical oncology, treatment

Introduction

The Algoma District Cancer Program (ADCP) is situated in Sault Ste. Marie, Ontario, Canada and services the needs of 125,000 individuals residing in a geographical area of approximately 49,000 km2.Maintaining standards of care in patients with prostate cancer can be challenging given the isolated environment in Northern Ontario.

Apart from skin cancer, prostate cancer is the most common cancer among men in North America (Canadian Cancer Society, 2016). Most men diagnosed with prostate cancer have a prognosis of at least five years, with a 98% 10-year survival rate and a 94% 15-year survival rate. However, for men diagnosed with metastatic prostate cancer, the 5-year survival rate drops from 99% to 28% (American Society of Clinical Oncology, 2016).

Prostate cancer is most commonly diagnosed based on an elevated prostate-specific antigen (PSA), with primary therapy often given for curative intent. Primary therapy consists of radical prostatectomy or radiation therapy, and is generally reserved for early stage cancers (Saad et al., 2015). Following primary therapy, the PSA is monitored to assess biochemical recurrence. PSA increases are seen in 20%-40% of patients and is often treated with androgen deprivation therapy (ADT). ADT temporarily prevents androgens from affecting prostate cancer cells, thereby controlling PSA in up to 85% of patients. ADT responsiveness varies among patients. Most prostate tumours eventually become refractory to ADT, which is known as castrate-resistant prostate cancer (CRPC). Once a patient has CRPC, they can be referred to a medical oncologist for further treatment and concurrent monitoring. The median survival for metastatic CRPC ranges between 12 to 24 months (Drake, 2010).

In conjunction with new treatment guidelines and the addition of two new medical oncologists at ADCP in July 2013, local referral processes were modified to accept prostate cancer patients earlier in their disease in January 2014. Prior to July 2013, there was only one medical oncologist working at ADCP. The objective of this project was to analyze the impact of this new referral process and subsequent treatment of patients with prostate cancer at ADCP.

 

Materials and methods

A retrospective chart audit looking at all prostate cancer patients seen by an ADCP medical oncologist from July 1, 2013 to February 16, 2016 was conducted. Ethics approval was received by The Joint Group Health Center/Sault Area Hospital Research Ethics Board. Electronic patient charts were analyzed for information including:

  • Date of diagnosis
  • Stage at time of referral
  • Date of first consult with a medical oncologist
  • Previous treatments trialed
  • Dates of previous treatments

Charts were separated in two groups: group 1 consisted of patients with a medical oncology (MedOnc) consult before December 31, 2013 and group 2 consisted of patients with a MedOnc consult after January 1, 2014. Data gathered compared both groups regarding the frequency of drug use and average number of lines of therapy received. This was done to determine whether there was evidence of improvement in local referral processes and adherence to standard guidelines. The different sizes of the two groups was acknowledged and considered when analyzing the data.

During analysis, use of anti-androgens, leutonizing hormone-releasing hormone (LHRH) agonists, LHRH antagonists, and chemotherapy were considered one line of therapy in a patient’s treatment course. However, abiraterone and enzalutamide were considered one line of therapy if used before chemotherapy and one line of therapy if used after chemotherapy.

 

Results

From July 2013 to February 16, 2016, 101 prostate cancer patients were seen by a medical oncologist at ADCP. 16 patients (16%) had a MedOnc consult prior to December 31, 2013 and 85 patients (84%) had a MedOnc consult after January 1, 2014. The number of patients seen each year increased as follows:

  • July 1-December 31, 2013: 16 patients
  • January 1-December 31, 2014: 23 patients
  • January 1-December 31, 2015: 52 patients
  • January 1-February 16, 2016: 10 patients

Group 1

At the time of consult with a medical oncologist, eight of 16 patients (50%) had stage four disease, while four patients (25%) had stage three disease, one patient (6%) had stage two disease, and three patients (19%) had stage one disease. On average, patients with a MedOnc consult prior to December 31, 2013 received two new lines of therapy before MedOnc consult and one new line of therapy after MedOnc consult (Table 1). Of note, patients with stage four disease received an average of two new lines of therapy before MedOnc consult and an average of two new lines of therapy after MedOnc consult (Table 2). Common lines of therapies provided by medical oncologists included both abiraterone and enzalutamide, used five and three times respectively (Table 3).

Group 2

At the time of MedOnc consult, 26 of 85 patients (31%) had stage four disease, while 26 patients (31%) had stage three disease, 18 patients (21%) had stage two disease, and five patients (6%) had stage one disease. These 85 patients had received an average of one new line of therapy before MedOnc consult and one new line of therapy after MedOnc consult (Table 1). Of note, stage four patients received an average of one new line of therapy before and after MedOnc consult (Table 2). Common lines of therapies provided by medical oncologists included abiraterone (used 11 times), enzalutamide (used four times), docetaxel (used five times), cabazitaxel (used two times), and radium-223 (used three times) (Table 3).

 

Discussion

The referral process modification at ADCP was ultimately aimed at having more patients with prostate cancer seen by medical oncologists to increase access to newer lines of therapy, as well as having a higher number of patients with prostate cancer seen at earlier stages of their disease. Prior to the arrival of new medical oncologists, evaluation of prostate cancer referral processes and treatment practices could not be adequately analyzed due to a lack of information. Therefore, the six-month period from July 1 to December 31, 2013 was used as a reference standard prior to new guideline implementation.

Before the modification, patients were referred with late stage disease and were unsuitable to pursue chemotherapy. These patients often died without being able to utilize all potential available therapies. After the referral process modification, more patients were seen at earlier stages in their disease and were therefore asymptomatic. This correlates with increased treatment modalities available. Patients are also more suitable to pursue chemotherapy.

Since many patients are now being seen in the early stages of their disease, there has not been a large need to provide more therapies. In addition, a higher number of patients have been able to receive systemic therapy since the referral process modification. At ADCP, it is predicted that more lines of therapy will be offered as a patient progresses in their disease, increasing the number of lines of therapy that a patient receives after their MedOnc consult.

This study lacks a large quantity of data that represents prostate cancer referral processes before the referral process modification. For this reason, the two patient groups largely differ in size, causing future analysis to become increasingly difficult. To combat this problem, future evaluations of this study may consider reorganizing the two patient groups for analysis, to ensure that all data produced is statistically relevant. As this project is being updated yearly, future directions would include continuing the analysis of the long-term effects of the referral process modification with a larger group of patients. Analysis of overall survival times and determining whether this referral process modification has had an effect would be useful to fully understand the benefit that modifying referral processes has given the Algoma District Cancer Program.

Overall, by modifying referral processes at the ADCP, a higher number of prostate cancer patients have been seen by medical oncologists earlier in their disease. Accepting patients at an earlier staged disease has increased access and exposure to therapies in symptomatic patients, thereby potentially increasing their overall survival. These changes have allowed medical oncologists at ADCP to maintain standard of care for prostate cancer patients, especially in those with metastatic disease. Men with prostate cancer in the Algoma District now have access to a higher number of therapies and equitable care.

 

Acknowledgments

Without the support and supervision of Dr. Silvana Spadafora, this research project would not have been possible. Thank you to both Dr. Silvana Spadafora and Dr. Mohammad Rassouli-Rashti for their medical expertise, to Dr. Michela Febbraro for her extensive reviews of the manuscript, and to Natalie Kovacevich for her assistance during the chart review.

 

References

American Society of Clinical Oncology. Prostate Cancer: Statistics. http://www.cancer.net/cancer-types/prostate-cancer/statistics. Published October 2014. Accessed January 5, 2016.

Canadian Cancer Society. Prostate Cancer Statistics. http://www.cancer.ca/en/cancer-information/cancer-type/prostate/statistics/?region=sk#. Updated 2015. Accessed January 5, 2016.

Drake, C. Novel Immune-based Therapies for Castrate-resistant Prostate Cancer: Implications for Patients and Practices. Medscape Multispecialty. http://www.medscape.org/viewarticle/725985. Published August 12, 2010. Accessed January 2, 2016.

Saad, F., Chi, K. N., Finelli, A., et al. The 2015 CUA-CUOG Guidelines for the management of castration-resistant prostate cancer (CRPC). Can Urol Assoc J. 2015; 9(3-4): 90-6. http://dx.doi.org/10.5489/cuaj.2526. Published online April 13, 2015.

 

 

Table 1. Average number of lines of therapy before and after a prostate cancer patient’s consult with a medical oncologist at ADCP

 

Patients with MedOnc Consult Before December 31, 2013 Patients with MedOnc Consult After January 1, 2014
Average Number of Lines of Therapy Before MedOnc Consult Average Number of Lines of Therapy After MedOnc Consult Average Number of Lines of Therapy Before MedOnc Consult Average Number of Lines of Therapy After MedOnc Consult
2 1 1 1

 

Table 2. Average number of lines of therapy before and after a prostate cancer patient’s consult with a medical oncologist at ADCP, specifically for patients with stage four disease

 

Stage 4 Patients with MedOnc Consult Before December 31, 2013 Stage 4 Patients with MedOnc Consult After January 1, 2014
Average Number of Lines of Therapy Before MedOnc Consult Average Number of Lines of Therapy After MedOnc Consult Average Number of Lines of Therapy Before MedOnc Consult Average Number of Lines of Therapy After MedOnc Consult
2 2 1 1

 

Table 3. Lines of therapy used by a medical oncologist after a patient’s consult at ADCP

Lines of Therapy Number of Times Used
Patients with MedOnc Consult Before December 31, 2013 Abiraterone 5
Enzalutamide 3
Docetaxel 0
Cabazitaxel 0
Radium-223 0
Patients with MedOnc Consults After January 1, 2014 Abiraterone 11
Enzalutamide 4
Docetaxel 5
Cabazitaxel 2
Radium-223 3

 

Filed in: Research

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