Marjan van den Akker

(1)

Comorbidity patterns in cancer survivors in the 21st century

(2)

Department of Family Medicine 2

• Background

• Comorbidity & multimorbidity

– concepts – relevance

– methodological challenges

• Comorbidity in cancer patients

– somatic – mental

(3)

Background

Ageing of the population:

• Cancer incidence ↑

• Treatment & survival à prevalence ↑

• Chronic diseases ↑

• Cancer survivors with comorbidity ↑

(4)

Comorbidity –

what are we talking about?

(5)

Cancer

(6)

How frequent is multimorbidity? - 1

Fortin et al, 2012, Ann Fam Med

(7)

How frequent is multimorbidity? - 2

0.44 Millions 0.71 Millions 1.13 Millions 1.84 Millions 3.17 Millions

³5 chronic diseases

³1 chronic disease

Relative increase since:

1994 2000 +40% +23%

+79.9% +40.2%

+128.8% +56.9%

+191.2% +76.4%

+256.5% +98%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Prevalence

Prevalence of chronic diseases in Flanders (Age−standardised rate)

(8)

% increase of chronic illness 2005 -

2025, the Netherlands (RIVM, NIVEL)

(9)

Comorbidity of cancer

• Additional (chronic) diseases, either present at the time of diagnosis, or occurring subsequently to the

diagnosis

(10)

Why is comorbidity a problem? 1 Patient

• Quality of life

• Treatment burden

• Informal caregivers

(11)

Why is comorbidity a problem? 2 Professional

• Difficult to interpret symptoms

• Multiple (conflicting) guidelines

’Co-morbidity: we need a guideline for each patient, not a guideline for each disease’

Dawes, 2010, Fam Pract

• Regular medication interactions with chemotherapy

(12)

Why is comorbidity a problem? 3 Patient & professional

• Compliance

• Shared decision making

(13)

Why is comorbidity a problem? 4 Cancer prognosis

• Directly: increased physiological burden of disease

• Indirectly: effects of comorbidity on treatment choice, timeliness and/or effectiveness of treatment

(14)

Why is comorbidity a problem? 5 Research

• Study population

– Cancer patients are heterogeneous group – RCTs often exclude patients with

comorbidity

– Recruitment of a vulnerable population

Koczwara B, ed. Cancer and chronic conditions. Springer, 2016

(15)

• Operationalisation and measurement

– Disease count

– Comorbidity index

§ CCI à National Cancer Institute CI

§ C3 (cancer specific)

§ ACE-27

(16)

• Information morbidity often incomplete

– Self-reported vs. physician diagnosed – EMR

– Cancer registries

– Administrative databases

Koczwara B, ed. Cancer and chronic conditions. Springer, 2016

(17)

Knowing all these difficulties,

(18)

Department of Family Medicine 18 Vos et al., BMC Fam Pract, 2015

(19)

Charlson comorbidity index (CCI)

cancer¹ no cancer¹ breast ca²

CCI 0 60% 85% 7%

CCI 1 19% 11% 32%

CCI 2+ 21% 5% 61%

(20)

Number of chronic diseases - 1

# diseases cancer¹ no cancer¹ breast ca² controls²

0 22% 22% 72% 81%

1 24% 24% 24% 17%

2+ 54% 54% 1% 1%

1. Deckx et al, J Canc Epidemiol, 2012

2. Schoormans et al, Acta Oncologica, 2015

1: chronic diseases from GP registration; #≈50 2: chronic diseases self-reported; # 8

(21)

# diseases cancer¹ no cancer¹ breast ca² controls²

0 22% 81%

1 22% 24% 72% 17%

2+ 24% 54% 24% 1%

3+ 54% 1%

1: chronic diseases from GP registration; #≈50

(22)

# diseases Thyroid ca Colorectal ca Hodgkin non-Hodgkin

0 25% 25% 46% 29%

1 31% 29% 31% 31%

2+ 44% 46% 23% 40%

Vissers et al, J Canc Survivorship, 2013

chronic diseases self-reported; # 14

(23)

Pre-existing diseases – top 5

Cancer (%) No cancer (%)

1. DM 15.3 15.6

2. Lipid disorders 13.2 13.0

3. Ischemic HD + angina 11.9 11.1

4. MI 10.6 9.7

5. Ischemic HD – angina 10.3 9.6

COPD 9.9 7.9*

Dementia 1.6 2.9*

(24)

Subsequent diseases – differences

Cancer (%) No cancer (%)

DVT (<2yrs) 0.93 0.21*

Hypertension 0.37 0.56*

Lipid disorders 0.37 0.76*

BPH 0.51 1.09*

NS: DM, osteoporosis, COPD, HF, CVA, IHD, dementia

Deckx et al, J Cancer Epidemiol, 2012

(25)

Prevalence (12-month rates) mental disorders

Any mood

% Any anxiety

%

Active cancer 8.9 13.5

Cancer survivors 6.0 12.5

No cancer 6.0 11.1

(26)

Association incident cancer – mental disorder

Mental disorder cancer vs. no cancer OR (95% CI)

Major depression 3.6 (1.4-8.8)

Drug dependence 3.6 (1.3-9.8)

Agoraphobia 3.3 (1.0-10.4)

Simple phobia 2.5 (1.0-6.2)

NS: dysthymia, bipolar, alcohol dependence, social phobia, panic attack/disorder, generalized anxiety disorder, PTSD

Honda et al, 2004, Psychother Psychosom

(27)

Association long-term cancer survival (≥5 yrs) – anxiety

Mental disorder cancer vs. no cancer OR (95% CI)

Any anxiety disorder 1.49 (1.04-2.13)

Specific phobia 1.59 (1.06-2.44)

Medical phobia 3.45 (1.15-10.0)

NS: social anxiety, generalized anxiety, PTSD, panic disorder, agoraphobia

(28)

Prevalence mental disorders cancer patients in acute care hospitals

Singer et al, 2010, Ann Oncol

(29)

Cancer, depression and coping

• Cancer patients

– avoiding coping à depression ↑

– active coping à depression ↓ (when higher educated)

– seeking social support à depression ↓ ()

(30)

Points of interest in mental care for cancer patients

• Treatment gap common mental disorders à screening

• Explore possibilities to support effective coping strategies

(31)

Wrapping up

• Many patients with cancer have comorbidity; somatic / mental

• No information about patterns ≥ 2 dis.

– Importance of comprehensive medical info – Treatment and disease interactions

– Treatment burden for patients

(32)