Prevalance and Cost of Chemotherapy use of towards End of Life among Cancer Patients at Ocean Road Cancer Institute from January to December 2023
Nanzoke Mvungi*
Consultant Clinical Oncologist, Ocean Road Cancer Institute (ORCI), P o Box 3592, Chimara Rd Dar Es Salaam-Tanzania
*Corresponding author
*Nanzoke Mvungi, Consultant Clinical Oncologist, Ocean Road Cancer Institute (ORCI), P o Box 3592, Chimara Rd, Dar Es Salaam-Tanzania
Abstract
Background: Chemotherapy are cytotoxic drugs that when administered to patients are sometimes accompanied with a number of adverse effects varying severity of toxicity. Patients with performance of more than ECOG 3 are usually weak, and palliative chemotherapy to them will add more impairments of their health hence may precipitate death. In Tanzania, most of cancer patients struggle with many society contributions to buy these drugs in continuing fighting cancer disease even when the hope of improving their survival is minimal. Thus, this study determined the magnitude of chemotherapy administration near the end of life as well as the cost that patients are incurring in purchasing chemotherapy.
Study objective: This study aimed to determine prevalence and cost of chemotherapy towards end of life on cancer patients at Ocean Road Cancer Institute from January to December 2023.
Methodology: This was a hospital based observational retrospective study and aimed to evaluate the incidence and cost of end-of-life chemotherapy on cancer patients at ORCI from January to December 2023. Participants who fitted our inclusion criteria were selected from death record book and recruited by our research assistant. Data of social demographic, number of days they received chemotherapy before death, comorbidities and adverse events of chemotherapy through common toxicity criteria version 5 were abstracted and recorded into standard questionnaire.
Results: A total of 424 death cases were recruited and analysed. 63% of the death cases were female and median age (IQR) at death was 56 (45, 66). Almost 50% of the cases were from Coast region and majority of them were uninsured 263(62%) and unemployed 395(93.1%). Cases with comorbidities were 133 (31.4%) and HIV positive was found to be 62 (14.6%). The leading mortality causing malignancy was pelvic malignancies and accounted for 135 (31.8%). About 60.6% of the cases were exposed to chemotherapy as the modality of treatment whether as concurrent or definitive treatment, 20% of cancer patients were exposed to chemotherapy in the 30 days of the end of life and 6.6% were documented to experience notable adverse effects like bone marrow suppression, severe mucositis, and etc. There was no statistically significant association of death and chemotherapy administration within 30 days of end of life. The cost of chemotherapy given in the last 30 days of life was 29,208,300/= TZS.
Conclusion: ORCI has shown a very good clinical practice as the number of chemotherapy usage towards the end of life was insignificant.
Recommendations: Annual analysis of these data is very important to our clinical practice.
Abbreviations: ORCI: Ocean Road Cancer Institute; ECOG: Eastern Cooperative Oncology Group; LMIC: Lower middle-income countries; ASCO: American Society of Clinical Oncology; IRB: Institutional Review Board; CTVAE: Common toxicity criteria version
Introduction
Background
Chemotherapy prescription near the end of life has always been a challenging decision to Oncologist, patients and family. End of life chemotherapy means chemotherapy administered to cancer patients during last 30 days of their lives [1]. In Tanzania, most new cancer patients tend to presents for cancer care when they are already in stage III-IV. Most of these patients will need palliative treatment of either chemotherapy or radiotherapy or combination of both depending on patient presentation. Most of advanced stage cancer patients feed poorly which tends to impair their quality of life [1,2]. In lower middle-income countries (LMIC) like Tanzania, most of cancer patients can hardly afford the convention chemotherapy, which are accompanied with a number of adverse effects. These adverse effects can lead into either frequent or longer stay hospitalization for patients.Normally chemotherapy in advanced stage cancer patients is aimed to help patients either live longer or improve disturbing symptoms hence live a better life. Solid tumors are among the most common malignancies presenting at ORCI (ORCI cancer trend) and chemotherapy has a role of prolonging survival for these malignancies [3].
Cancer specialist plans cancer treatment depending on a number of factors including status and preference of patient, stage of disease and prognostic indicators of a certain cancer types. With the assistance of National cancer treatment guidelines, cancer specialist plans appropriate management of a case. Due to late presentation of most of patients with advanced diseases, most of the plans tends to be of palliative intention of either medical only or medical and either chemotherapy or radiotherapy. For such cases with medical palliation only, patients and relatives tend to continue opting for palliative chemotherapy due to a number of reasons; culturally one being the feeling of wanting to continue fighting the disease [3,4]. Study done by Alexi et al on Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death found 60% of terminal ill cancer patients wanted palliative chemotherapy even when it could add one week to their living rather than medical palliative care modality alone. This shows a high demand of most of terminal ill cancer cases to prolonging more life even with poor quality of it. Also, this same study found the difficulty in stopping of palliative chemotherapy to patients on discussion with patients, caregivers and cancer specialist. This challenge has led to dis-proportional palliative chemotherapy usage near end of life of different cancer centers.
Most of the International guidelines including the American Society of Clinical Oncology (ASCO) recommends palliative chemotherapy for palliation of pain and improving of survival to patients with metastatic cancer with good performance status, and does not recommend palliative chemotherapy to patients with metastatic cancer with poor performance status. According to ORCI data, most of newly diagnosed cancer patients come to ORCI with advanced stages of disease including metastatic hence planned for either palliative chemotherapy or radiotherapy depending on patient presentation [3-5]. Chemotherapy are cytotoxic drugs that when administered to patients are sometimes accompanied with a number of adverse effects varying severity with toxicity grading criteria. Patients with performance of more than ECOG 2 are usually weak, and palliative chemotherapy to them will add more impairments of their health hence may precipitate them into premature death [5,6].
Problem Statement
Chemotherapy near the end of life is challenging and demonstrate a poor clinical practice by clinicians. ORCI provides chemotherapy to about 300 cancer patients per week including patients near end of life. Study done by Daniel Low et al in Uganda found that more than 45% of cancer patients received chemotherapy near the 30 days end of life.
In developed cancer centers, some studies have shown cancer patients who received chemotherapy near the end of life encountered economic burden and impairing of their health and some even led into death but in Tanzania, we do not have these data.
Rationale
In most of developing countries like Tanzania, chemotherapy near the end of life has not been studied intensively. Chemotherapy within last 30 days of life is burdening patients and family economically as well as impairing quality of life of cancer patients. Thus, this study has been done in order to provide baseline information on prevalence, cost of chemotherapy near the end of life so that policy makers and clinicians are informed, and provide solutions in offering best care to improve the outcome our patients.
Study Objective
Broad objective
To determine the prevalence and cost of chemotherapy near the end of life among cancer patients at Ocean Road Cancer Institute from January 2023 to December 2023.
Specific objectives
To determine the social demographic characteristics our study participants.
- To determine prevalence of cancer type versus death.
- To determine the incidence of chemotherapy near the end of life.
- To determine the cost of chemotherapy prescribed during end of life.
Research Hypothesis
Hypothesis
Ho1: There is no incidence of chemotherapy administration near the end of life on cancer patients.
HA1: There is incidence of chemotherapy administration near the end of life on cancer patients.
Hypothesis
Ho1: There is no prevalence of cancer type versus death.
HA1: There is prevalence of cancer type versus death.
Hypothesis
Ho1: There is no cost of chemotherapy prescribed during end of life.
HA1: There is cost of chemotherapy prescribed during end of life.
Methodology
Study Setting: This study was conducted at ORCI in Dar es Salaam, Tanzania. ORCI is the National referral hospital for cancer treatment and provides cancer care to an estimated 7,000 new cancer patients per year.
Study design: This was an observational retrospective study and aimed to evaluate the incidence and cost of end-of-life chemotherapy on cancer patients at ORCI from January 2023 to December 2023. Participants who fit our inclusion criteria were selected from death record book and recruited. Data of social demographic, number of days that died cases received chemotherapy before death and adverse events of chemotherapy through common toxicity criteria version 5 were abstracted and recorded into standard questionnaire.
Target Population: All cancer cases that died at ORCI.
Study Population: All died cases from January to December 2023.
Eligibility Criteria
Inclusion Criteria
All cancer cases that died at ORCI.
- Age 18 years of age or older
- Patients with Tanzanian citizenship
Exclusion criteria
All cancer cases that did not die at ORCI.
Sample Size: Mortality rate at ORCI is about 60 cases per month, which makes about 720 cases per year hence we enrolled 424 cases in our study.
Dependent variables: Outcome: - Chemotherapy near the end of life, number of days patient received chemotherapy before death, cost and adverse effects of chemotherapy.
Independent variables: Disease profile – histology, stage and social-demographic data.
Data collection: Once a potential study participant was identified, a research assistant under the supervision of principal investigator assessed eligibility criteria and enrolled the participant in this study. Participants were randomly selected from the death record book and recruited. Each participant file was pooled and social demographic information, type of chemotherapy and days of chemotherapy to death were abstracted and recorded into a standardized structured questionnaire.
Ethical clearance: Permission to do research was sought from Ocean Road Cancer Institute (ORCI) Ethics committee (IRB).
Data analysis: Data were cleaned, entered and analyzed using Statistical Package for Social Scientists version 21.0. Socio-Demographic characteristics will be summarized using frequency distribution and relationship between variables; end of life chemotherapy and cost were done by chi-square test and multivariate analysis.
A total of 424 death cases were recruited and analysed. 63% of the whole cancer death were female and median age (IQR) at death was 56 (45, 66). Almost 50% of the cases were from Coast region and majority of them were uninsured 263(62%) and unemployed 395(93.1%). Cases with comorbidities were 133 (31.4%) and HIV positive was found to be 62 (14.6%). The leading mortality causing malignancy was pelvic malignancies and accounted for 135 (31.8%).
About 60.6% of the cases were exposed to chemotherapy as the modality of treatment whether as concurrent or definitive treatment, 20% of cancer patients were exposed to chemotherapy in the 30 days of the end of life and 6.6% were documented to experience notable side effects. The identified side effects according to chemotherapy were bone marrow suppression, severe mucositis, renal compromise and gastroenteritis. For the chemotherapy given in the last 30 days of life a total amount of 29,208,300/= TZS was spent for the medications alone.
Table 1: Sociodemographic and Clinico-Pathological Characteristics. N=424.
Table 2: Treatment Evaluation.
Table 3: Possible Associations with Chemotherapy Given in 30 Days of End of Life.
(This analysis is only on the patients who received chemotherapy as their mode of treatment).
There was no statistically significant association of death with either age, gender, comorbidity, disease stage, treatment received and chemotherapy administration within 30 days of end of life.
Discussion
The purpose of this study was to determine the prevalence and cost of chemotherapy administration near the end of life among cancer death at Ocean Road Cancer Institute. Our findings show that; a total of 424 cancer death cases were recruited and analysed. 63% of the whole death were female and median age (IQR) at death was 56 (45, 66). Almost 50% of the cases were from Coast region and majority of them were uninsured 263(62%) and unemployed 395(93.1%). The female gender is highly affected compared to male gender and median age was 56 years which is inconsistency to the study done by Daniel Low et al on chemotherapy use at the end of life in Uganda as in Uganda the two genders were equally affected and median age was 46 years. (7) However, ORCI new cancer cases trend also reflect the same gender distribution as our findings hence even death follows the pattern of our new cancer cases trend.
About 60.6% of the cases were exposed to chemotherapy as the modality of treatment whether as concurrent or definitive treatment, 20% of cancer patients were exposed to chemotherapy within 30 days of the end of life and 6.6% were documented to experience notable side effects. The identified side effects according to chemotherapy were bone marrow suppression, severe mucositis, renal compromise and gastroenteritis. These findings are inconsistent with Uganda by Daniel Low as they showed 68.9% of chemotherapy administration towards the end of life [7]. The fact that 75% cancer patients from Uganda and Tanzania presents with stage III and IV, reflects the greater disease burden and sometimes could push physicians to prescribe more chemotherapy even towards the end of life. Despite of the advanced stages these patients presented with, but sometimes patients and relatives tend to seek more aggressive therapy for their disease management even after being counselled on disease prognosis. The observed total cost of cytotoxic drugs only was Tsh 29,208,300/= (10814.08 USD). This cost is a sum of all chemotherapy drugs consumed by 73 patients towards 30 days of end of life which is equivalent to Tsh 400,113.7/=(148.1USD) per patient. This was one component of indirect cost encored by patient which reflect how common Tanzanian patients and relatives are struggling during these difficult times. Government of Republic of Tanzania through its Ministry of Health, Ocean Road Cancer Institute has been providing subsided/zero cost prices of cancer management in chemotherapy, accommodation, consultations and investigations to her Tanzanian cancer patients. This Institutional cost is still high especially when you compare chemotherapy management with other medical palliative care modality. Hence physicians are encouraged to use strong prognostic criteria whenever palliative chemotherapy is highly considered as the treatment modality.
Conclusion
ORCI has shown a very good clinical practice as the number of chemotherapy usage near the end of life was insignificant.
Recommendation: Annual analysis of these data is very important to our clinical practice.
PRINCIPAL INVESTIGATOR: NANZOKE THEBALD MVUNGI MD, MMED CLINICAL ONCOLOGIST AT ORCI. OTHER INVESTIGATORS; DR MAMSAU TWALIBU NGOMA AND DR HERRIETHSIAH NOAH MD AT ORCI.
REFERENCES
1. Holly G (2015) Chemotherapy Use, Performance Status, and Quality of Life at the End of Life JAMA Oncol 1 (6):778-784.
2. Indryas W (2022) Chemotherapy during the last 30 days of life and the role of palliative care referral, a single center experience BMC Palliative Care p. 21.
3. https://www.orci.or.tz/epidemiology-and-biostatistics/
4. Braga S (2011) Why do our patients get chemotherapy until the end of life? Ann Oncol (11): 2345-2348.
5. Eastern Cooperative Oncology Group (2015) ECOG performance status.
6. Schnipper LE, Smith TJ, Rashaan D (2012) American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol 30(14):1715-1724.
7. Chemotherapy Use at the End of Life in Uganda January 2017 Journal of Global Oncology 3(6): JGO.2016.007385.