Transcript ASCO_2008_files/Love physician pref adj Tx ASCO2008 Poster

Which Adjuvant Systemic Treatments
Would Medical Oncologists Wish to
Receive If They Had Colon Cancer?
A Survey of 150 Physicians
N Love, MD1; NJ Meropol, MD2; PM Ravdin, MD3; C Bylund, PhD4;
LM Ellis, MD3; A Grothey, MD5; HJ Lenz, MD6; JL Marshall, MD7; SA
Curley, MD3; D Paley, BA1; M Elder, BBA1
1 Research
To Practice, Miami, FL; 2 Fox Chase Cancer Center, Philadelphia, PA;
3 The University of Texas MD Anderson Cancer Center, Houston, TX; 4 Memorial
Sloan-Kettering Cancer Center, New York, NY; 5 Mayo Clinic College of Medicine,
Rochester, MN; 6 USC/Norris Comprehensive Cancer Center, Los Angeles, CA;
7 Lombardi Comprehensive Cancer Center, Washington, DC
Background
As with many treatment decisions in current medical
oncology practice, the choices regarding adjuvant
chemotherapy for colon cancer are challenging for
both patients and physicians because:
1.
Potential benefits may be modest in the face
of substantial risks.
2.
The optimal management of Stage II disease
is controversial (Benson 2004).
3.
Relatively nontoxic (compared to chemotherapy)
experimental biologic agents offer more choices
in the form of adjuvant clinical trial participation
and off-label treatment.
Background (continued)
One strategy many patients use to help
with clinical decision-making is asking their
physicians, “What would you do, Doctor?”
(Sokol 2007).
The ethical implications of this approach
are complex, and it has been observed that
physicians don’t always select the same
treatment for themselves as they would
for their patients (Gardner 2005).
Background (continued)
This study attempted to determine:

How often medical oncologists are asked by
their patients facing a decision about adjuvant
therapy for colon cancer what treatment they
would receive if they were in the same situation.

Whether oncologists’ personal selections differ
from standard treatment recommendations and,
if so, for which specific clinical situations.
Methods
US-based medical oncologists who treat patients
with colon cancer were recruited to participate in a
10-minute online survey in September 2007.
More than 5,600 medical oncologists who
subscribe to Research To Practice’s educational
programs were invited to take part by external
market research company Medimix International.
The study remained open until the goal of 150
eligible respondents was reached.
Methods (continued)
The survey was divided into three sections:
1.
Participant oncologist’s estimate of the fraction of
patients considering adjuvant chemotherapy for colon
cancer who ask what therapy the treating physician
would select if in the same situation and how the
participant generally responds
2.
Survey of treatment recommendations for a
hypothetical 55-year-old patient in five different
adjuvant clinical decision-making scenarios (Table 1)
3.
Survey of personal treatment choices the participant
would make as a patient in the same five identified
adjuvant clinical decision-making scenarios
Table 1
SCENARIOS PRESENTED
Scenario
Description
1
Stage III colon cancer: 2/18 positive nodes
2
Stage III colon cancer: 15/18 positive nodes
3
Stage II colon cancer: 8 negative nodes, no other highrisk features
4
Stage II colon cancer: 18 negative nodes, no high-risk
features
5
Colon cancer and the following five-year risks of
relapse from Adjuvant! Online data (equivalent to
Scenario 4 but not identified as such):
 With no further treatment: 13.0 percent
 With 5-FU or capecitabine: 10.5 percent
 With oxaliplatin/5-FU: 8.1 percent
Results
Respondent demographics

75 percent of participants were male.
 Median age was 48 years, ranging from 31 to 71 years.
Overall

Participants estimated that 41 percent (mean) of their
patients facing a decision about adjuvant therapy for
colon cancer ask how the participant would wish to
be treated as a patient in a similar situation (SD =
29.19).

70 percent of participants regularly provide an answer
to this question (Figure 1).
Figure 1
When patients ask what therapy you would select if you were
in the same situation, how do you generally respond?
I never or almost never
provide an answer to this
type of questioning
6%
I prefer not to respond,
but if pressed will provide
an answer
20%
I regularly tell patients
what my decision would
most likely be
70%
Other
4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Results (continued)
Overall

Participants estimated that only about half of
their patients considering adjuvant therapy for
colorectal cancer were interested in information
about treatment options and wished to be
actively involved in decision-making.

Participants’ recommendations to patients were
identical to their personal treatment choices for
73 percent of responses (Figures 2-3).
Results (continued)
Participants’ treatment recommendations versus
their personal treatment choices for Stage III
disease (Figures 2A-2B)

Standard oxaliplatin-based chemotherapy or
clinical trial participation were recommended and
chosen more frequently than off-study
chemotherapy combined with biologic treatment.

The option of participation in a clinical trial with
bevacizumab was one of the two most frequently
recommended and chosen treatments for Stage
III disease.
Results (continued)
Participants’ treatment recommendations versus
their personal treatment choices for Stage III
disease (Figures 2A-2B)

Trials evaluating bevacizumab were favored as
recommendations and choices over studies with
cetuximab (p < 0.01).

Participants more frequently selected off-protocol
bevacizumab for themselves as patients than they
recommended as routine care of patients with
Stage III disease (p < 0.05), but 90 percent of
participants did not recommend and 74 percent
would not receive off-protocol biologic agents
even for high-risk disease.
Figure 2A
Recommendations for a 55-year-old patient and the
treatments oncologists would choose as patients
Stage III colon cancer, 2/18 positive nodes
51%
44%
FOLFOX
Trial: FOLFOX vs
FOLFOX + bevacizumab
30%
31%
6%
7%
Capecitabine + oxaliplatin
Trial: FOLFOX vs
FOLFOX + cetuximab
5%
3%
4%
FOLFOX + bevacizumab*
5-FU/LV + bevacizumab
2%
1%
Other
2%
3%
0%
*p
< 0.05
11%
Would recommend
to a patient
Would choose
if he/she were
a patient
10% 20% 30% 40% 50% 60%
Figure 2B
Recommendations for a 55-year-old patient and the
treatments oncologists would choose as patients
Stage III colon cancer, 15/18 positive nodes
31%
FOLFOX
23%
Trial: FOLFOX vs
FOLFOX + bevacizumab
50%
42%
3%
3%
Capecitabine + oxaliplatin
Trial: FOLFOX vs
FOLFOX + cetuximab
5%
3%
10%
FOLFOX + bevacizumab*
5-FU/LV + bevacizumab
Other
1%
1%
< 0.05
26%
Would choose
if he/she were
a patient
0%
2%
0%
*p
Would recommend
to a patient
10% 20% 30% 40% 50% 60%
Results (continued)
Participants’ treatment recommendations versus
their personal treatment choices for Stage II disease

With only eight nodes examined, most
participants would recommend and choose
adjuvant systemic treatment (Figure 3A).

Participants would elect to receive adjuvant
chemotherapy for lower-risk Stage II disease
somewhat more frequently than they would
recommend it for their patients (Figure 3B).
Figure 3A
Off-protocol recommendations for a 55-year-old patient and
the treatments oncologists would choose as patients
Stage II colon cancer, 0/8 negative nodes,
no other high-risk features
47%
48%
FOLFOX
19%
14%
5-FU/LV alone
16%
16%
No chemotherapy
13%
14%
Capecitabine alone
Capecitabine +
oxaliplatin
Other
Would recommend
to a patient
Would choose
if he/she were
a patient
4%
8%
1%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Figure 3B
Off-protocol recommendations for a 55-year-old patient and
the treatments oncologists would choose as patients
Stage II colon cancer, 0/18 negative nodes,
no high-risk features
9%
FOLFOX
14%
11%
13%
5-FU/LV alone
No chemotherapy*
53%
8%
Capecitabine alone*
1%
3%
< 0.05
Would choose
if he/she were
a patient
1%
0%
0%
*p
Would recommend
to a patient
17%
Capecitabine +
oxaliplatin
Other
70%
10%
20%
30%
40%
50%
60%
70%
80%
Results (continued)
Participants’ treatment recommendations versus
their personal treatment choices for Stage II disease

Although adjuvant therapy is not usually
recommended for patients with Stage II colon cancer
without high-risk features, when presented only with a
set of quantitative recurrence risks derived from
Adjuvant! Online for that clinical scenario, almost all
participants would recommend and choose adjuvant
treatment (Figures 3B & 4).
Figure 4
Case based on Adjuvant! Online data:

Five-year risk of relapse with no further treatment: 13.0 percent
 Five-year risk of relapse with 5-FU or capecitabine: 10.5 percent
 Five-year risk of relapse with oxaliplatin/5-FU: 8.1 percent
83%
78%
FOLFOX
5-FU/LV alone
No chemotherapy
3%
4%
4%
3%
Capecitabine alone
3%
7%
Capecitabine + oxaliplatin
7%
8%
Would recommend
to a patient
Would choose
if he/she were
a patient
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Conclusions

A significant proportion of patients with colon cancer
regularly ask their medical oncologists what their personal
treatment choices would be in the same situation, and most
clinicians provide an answer.

Participants generally recommend the same treatments to
their patients that they would choose for themselves.
However, for certain clinical scenarios, a higher fraction of
clinicians favored more proactive personal treatments.

Most medical oncologists would not elect to receive biologic
agents off protocol even for high-risk Stage III disease, and
participation in clinical trials evaluating these agents was a
more common choice. However, for Stage III disease with two
positive lymph nodes, only one third of the participating
oncologists would recommend and elect clinical trial
participation.
Conclusions (continued)

Approximately half of medical oncologists would receive
treatment in a situation perceived qualitatively as “lower-risk
Stage II,” yet almost all would receive treatment based on the
quantitative risk reductions for a similar case as described in
Adjuvant! Online. This likely reflects ongoing uncertainty
about the benefit of adjuvant chemotherapy for Stage II
disease but also suggests that medical oncologists would
quickly adopt this treatment approach even for a relatively
small reduction in recurrence risk if convinced that this
modest benefit exists.

This survey was hypothesis generating, and further study is
warranted to determine whether the perceptions of this small
cohort are representative of the broad oncologist community.
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Acknowledgment
This work was supported by
an educational grant from Sanofi-Aventis.