Unplanned Hospital Visits during Chemotherapy
Forty-five percent (45%) of breast cancer patients who receive adjuvant chemotherapy, 48% of colon cancer patients who receive adjuvant IV chemotherapy, 38% of patients who receive adjuvant oral-chemotherapy and 52% of lymphoma patients who receive chemotherapy visit the emergency department (ED) or are admitted to hospital at least once during the course of chemotherapy treatment. A high number of patients visit a second or third time. These results suggest that side effects do occur and resources are needed for patients to self-manage complications where appropriate, while also having a place where they can call or go when they require evaluation or management.
Measure: Percentage of breast, colon and lymphoma cancer patients visiting the hospital at least once during a course of chemotherapy treatment
As of this Report:
What are chemotherapy, adjuvant chemotherapy and neutropenia?
- Chemotherapy treatment is the use of drugs that slow or stop cancer cells from growing, multiplying or spreading to other parts of the body . Chemotherapy is administered in the form of pills (oral), injection or intravenously (IV).
- Chemotherapy is often given in cycles to allow the body to rest and recover.
- Adjuvant chemotherapy means that chemotherapy treatment is given after the removal of tumours through cancer surgery. Adjuvant chemotherapy has been shown to increase the chance of killing any remaining non-visible cancer cells, prevent recurrence (return) of cancer, prolong life and improve the chance of curing a patient’s cancer.
- In addition to destroying cancerous cells, chemotherapy drugs can suppress bone marrow function by killing white blood cells, which are essential for protection against illness and disease. As a result, patients receiving chemotherapy treatment may be more likely to develop infections.
- A decrease in neutrophils, a type of white blood cell, is called neutropenia. If accompanied by a fever, it is called febrile neutropenia, and it can be a sign of an underlying infection.
- In treating lymphoma, the most common combination of drugs used is a regimen called CHOP, which includes the drugs cyclophosphamide, doxorubicin, vincristine and prednisone(can be referred to as prednisolone). CHOP is often combined with targeted therapy, which focuses on a specific protein associated with the lymphoma, leading to the destruction of these cancer cells . Often, the antibody rituximab (Rituxan®) is used in combination with chemotherapy drugs (where it is known as R-CHOP).
What is the New Drug Funding Program?
- The New Drug Funding Program (NDFP) provides equal drug access for all Ontarians by paying for chemotherapy regimens that have been evaluated and approved for coverage by the Ministry of Health and Long-Term Care.
- This section measures how many breast, colon and lymphoma cancer patients being treated with NDFP drugs, either after surgery or as a primary treatment, visited the ED 1 or more times for care and/or needed to be admitted to hospital over the total duration of their chemotherapy treatment.
What is an unplanned visit during chemotherapy?
- An unplanned visit occurs when a patient has an ED visit or is admitted to the hospital during a course of chemotherapy treatment, presumably because of a side effect or adverse event.
I had a number of problems with chemo – lots of side effects – none of which anyone prepared me for or much assistance how to cope with them - I struggled through.
– Joanne M., Patient/Family Advisor
What do the results show?
ED visits and hospital admissions are common (Figures 1 to 4).
- Forty-five percent (45%) of breast cancer patients who receive adjuvant chemotherapy, 48% of colon cancer patients who receive adjuvant IV chemotherapy (colon-IV), 38% of colon cancer patients who receive adjuvant oral chemotherapy (colon-oral) and 52% of lymphoma patients visited the ED at least once during chemotherapy treatment.
- Of the patients who visited the ED at least once, 21% of breast cancer patients, 19% of colon-IV cancer patients, 32% of colon-oral cancer patients and 42% of lymphoma patients were admitted to hospital (Figure 1).
- In addition to the patients who visited the ED, 2% of breast cancer patients, 2% of colon-IV cancer patients, 2% of colon-oral cancer patients and 9% of lymphoma patients were admitted directly to hospital.
- There is some regional variation in patients who visited the hospital during treatment, ranging from 39% to 67% for breast cancer patients, 38% to 72% for colon-IV cancer patients, 20% to 80% for colon-oral cancer patients and 54% to 70% for lymphoma patients.
- Time trend data indicate that unplanned hospital visits for colon and lymphoma cancer patients remained relative stable from 2010 to 2015 (Figures 3 and 4).
- There has been a decrease in the number of unplanned hospital visits for breast cancer patients (from 47% in 2014 to 44% in 2015). This could be a result of the approval by the Ontario Drug Benefit of a new intervention (growth factor support using filgrastim, which is sold under the brand names of Grastofil® and Neupogen®) to decrease risk of febrile neutropenia, a known chemotherapy complication. It also could be a result of work done within the regions to expand access to knowledgeable oncology providers 24 hours a day, 7 days a week.
- Unplanned hospital visits are also reported after cancer surgery.
Almost half of patients with breast or colon-IV cancer visited the ED a second time during a course of treatment. Percentages were even higher for lymphoma patients (Figures 5, 6 and 7).
- About 47% of breast and 48% colon-IV cancer patients who visited the ED returned for a second ED visit, and approximately 23% of breast and 24% of colon-IV returned for a third visit. Forty percent (40%) of colon-oral cancer patients and 59% of lymphoma patients returned a second time, and 17% and 36%, respectively, returned a third time.
- For breast and colon-IV cancer patients, 6% and 7%, respectively, returned to the hospital 5 or more times (compared to 2% of colon-oral patients and 13% of lymphoma patients).
- Age and rate of hospital visits are positively associated among colon-IV and lymphoma cancer patients. Lymphoma patients and colon cancer patients who received IV chemotherapy had the highest unplanned hospital visits for patients age 65 and older.
- Colon cancer patients age 80 and over who received oral chemotherapy had the highest rates (44%) of unplanned hospital visits during chemotherapy compared to other age groups (Figure 6).
- This relationship does not hold true for breast cancer patients. Hospital visits differed by age and type of cancer. Breast cancer patients age 18 to 29 had the highest rates (59%) of visiting the hospital, compared to breast cancer patients age 80 and over (46%).
- These differences in age could be related to younger breast cancer patients being treated with more aggressive regimens of chemotherapy drugs than lymphoma and colon cancer patients, who all would receive the same regimens.
Many hospital visits are happening during the day, with hospital admissions varying by type of cancer and time of day (Figures 8 and 9).
- Approximately one-third of hospital visits took place during weekday business hours. About 37% of breast cancer, 35% of colon-IV cancer, 33% of colon-oral cancer and 31% of lymphoma patients had visits on the weekend.
- The weekday overnight time period had the lowest rate of hospital visits for breast cancer, colon-IV cancer, colon-oral cancer and lymphoma patients. However, patients who visited a hospital at this time also had the highest risk of hospital admission.
- Of the 4 patient groups, lymphoma patients had the highest rate of admission to hospital for any time of day, regardless of the day of the week.
- The differences seen among the types of cancer and the time of visit may reflect that some patients experience more serious symptoms.
- This analysis helps identify which visits may be preventable with better symptom management supports in the cancer system.
Why is this important to Ontarians?
Managing treatment-related side effects
- While chemotherapy for breast cancer, colon cancer and lymphoma patients has helped improve outcomes, the potential for drug-related side effects must be taken into account when balancing improvement in survival with aggressiveness of treatment.
- There is no standard for an acceptable rate of chemotherapy side effects.
- These drug-related side effects are potentially predictable, and they should be taken into account when setting individual treatment plans and planning appropriate system resources to care for these patients.
- By measuring the frequency of hospital visits resulting from the effects of chemotherapy treatment, Cancer Care Ontario aims to improve patient management and care by ensuring patients know who to call when they experience side effects and by eliminating unnecessary visits to the ED.
- In the 2014 Ambulatory Oncology Patient Satisfaction Survey (AOPSS), 83% of breast and colorectal cancer patients and 82% of lymphoma patients responded that someone had either “yes, completely” or “yes, somewhat” told them how to manage any side effects of chemotherapy (data not shown).
- These findings suggest that the problem is not whether information is being provided, but how and what information is being provided and how it is being used by patients. The hospital may be the appropriate place to evaluate and help certain patients, but there also may be other acceptable options.
- Provision of alternative strategies and clinics to deal with these patient issues outside of normal working hours would seem to be an appropriate goal.
Neutropenia, fever and infection may be preventable
- Growth factor support has been shown to decrease the rates of neutropenia after intravenous chemotherapy .
- Using growth factors preventively after some adjuvant, neoadjuvant or curative chemotherapy regimens may help reduce the rates of neutropenia and its complications.
Appropriateness of using the emergency department and hospital care
- Medical oncologists instruct patients to go to the ED if they experience serious side effects (such as fever) outside of normal clinic hours. Fever after chemotherapy needs to be evaluated quickly, and no other appropriate healthcare settings exist to receive patients when clinics are closed.
- From the point of view of cancer patients, EDs may not be the most appropriate care setting for support, treatment or management of all side effects. Other models of care could be considered, such as management of low-risk patients by urgent care centres and 24/7 access to knowledgeable oncology providers by phone.
Find out more
For more information on the Systemic Treatment Program, please visit Cancer Care Ontario’s website.