Analgesics Prescription to french

Cancer Survivors during the two first

years after diagnosis: a case-control

study.

Marc K. BENDIANE,

18thECCO-40thESMO, Vienna, 27 September 2015

Background and objectives......................................

1. Pain is a major symptom associated with cancer that could be

experienced by cancer survivors long time away after treatment.

2. For the ten last years, Medical international literature has showed that

in France access to strong analgesics treatment, especially Grade III,

seems to be limited for vulnerable groups such as women.

3. To document access to pain treatment, we focus on prescription of

Grade II and Grade III analgesics for cancer patients the first two years

after diagnoses using the last recent data from the VICAN survey.

4. So, we compared two cohorts of patients: one of cancer patients

(VICAN cases), and another of individuals without cancer (EGB

controls).

VICAN Survey a national survey among cancer survivors………………………….....

The cohort was restricted to 12 tumor

sites accounting for 88% of all-cancer

incidence in France in 2012 : breast (C50), lung (C33, C34), colorectal (C18-C20),

upper aerodigestive tract (C00-C14, C30-C32),

kidney (C64-C66), cervix (C53), endometrial cancer

(C54), non-Hodgkin lymphoma and melanoma

(C43), thyroid (C73), bladder (C67), prostate (C61).

Patients were randomly selected with

stratification for each tumor site (12

strata) and age at diagnosis (18-52 and

53-82).

This longitudinal survey investigates various topics related to cancer

survivorship 2 and 5 years after diagnoses among a large population-

based national sample of adults in France.

VICAN Data collection…………….…….…………....……

NHS Databases

The national SNIIR-AM database,

which includes financial

reimbursement data (for

physicians’ and other health

professionals’ consultations, and

for prescribed drugs) as well as

hospital discharge records.

CATI Interview

The CATI interview

questionnaire dealt with many

topics: sociodemographic

background and

socioeconomic status,

circumstances of diagnosis,,

treatments received and

perceived side effects such as

fatigue and pain….

Medical Survey

A medical survey was

conducted

with the physician who

initiated cancer treatment,

to collect detailed

information regarding

tumour histology (stage,

grade, size).

VICAN 2 cases, two years after a cancer diagnoses …………….…….…………....……

The first part of the VICAN survey was implemented in 2012 and targeted

adult patients with cancer diagnosed between January and June 2010.

2 years after cancer diagnosis, effectively in the ‘recovery’ phase, which

follows the primary treatment phase.

SNIIRAM data were collected for 16 429 cancer survivors

selected from the three Health Insurance Schemes : CNAMTS

for salaried workers, RSI for self-employed workers, MSA for

farmers.

4 349 cancer survivors participated at the CATI interview.

Medical data were available for 3 812 cancer survivors.

Controls were none cancer patients from the “Echantillon Généraliste

des bénéficiaires” (EGB) cohort. The EGB is a permanent

representative sample of the Health Insurance Schemes for salaried

workers (CNAMTS) that was obtained 1/97th national random sampling

.

Controls were matched to cases using a propensity score based on the

following matching variables:

1. age in 2010 (year of cancer diagnosis for all cases),

2. gender,

3. has purchased grade II or grade III precribed analgesics medication

6-12 months before cancer diagnosis (Yes/No),

4. has purchased precribed psychotropics medication 6-12 months

before cancer diagnosis (Yes/No),

5. pre-diagnosis somatic multimorbidity score,

6. carstairs index of the place of residence.

EGB matched controls, no cancer patients………………………………….…….…………....……

EGB Limitation N = 8 526 case-control pairs involved……………………..…………....

We restrict this set of analyses to 8 526 case-control pairs.

1- From 2009 to 2012, EGB ‘cohort’ data were only available for

patients registered with the main Health Insurance Scheme for

salaried workers(CNAMTS) which cover 80% of the french population.

2- EGB do not record prescriptions dispensed by public or private

hospitals during hospital stays.

For each selected case and control, we retrieved data from the NHIF

databases on the following drugs dispensed in community from

January 2009 to December 2012 using the ATC classification:

Grade II analgesic drugs: Codeine (ATC : N02AA59, N02AA79), Dextropropoxyphene

(ATC: N02AC04, N02AC54, N02AC74), Tramadol (ATC: N02AX02, N02AX52)

Grade III analgesic drugs: Morphine (ATC: N02AA01), Fentanyl (ATC: N02AB03),

Oxycodone (ATC: N02AA55, N02AA05), Buprenorphine (ATC: N02AE01), Nalbuphine (ATC:

N02AF02).

Annual prevalences of analgesic drug prescriptions in cancer patients and their

matched controls (N = 8 526 case-control pairs)*

First year after

cancer diagnosis† (%)

Second year after

cancer diagnosis† (%)

VICAN Matched

controls VICAN

Matched

controls

Grade II/III

analgesics 53.4 24.3 32.7 20.6

Grade II analgesics 51.8 24.0 30.5 20.3

Grade III analgesics 9.2 0.9 7.1 1.0

* All case-controls differences significant at p<0.0001. † For controls, age was determined using their matched case’s date of cancer diagnosis as a reference.

Analgesic drugs prescription

Grade II Risk ratio (cancer/no cancer)

with 95% CI

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

-12 -6 0 6 12 18 24

months since cancer diagnosis 0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

-12 -6 0 6 12 18 24 months since cancer diagnosis

Grade III Risk ratio (cancer/no cancer) with 95% CI

Analgesic drugs prescription………………….gender

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

-12 -6 0 6 12 18 24

months since cancer diagnosis

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

-12 -6 0 6 12 18 24

months since cancer diagnosis

Risk ratio for men

Risk ratio for women

Grade 2 prescription (cancer vs no cancer) Grade 3 prescription (cancer vs no cancer)

Risk ratio for men

Risk ratio for women

0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

-12 -6 0 6 12 18 24

months since cancer diagnosis

Analgesic drugs prescription ……………………age

Risk ratio for 18-52 years old

Risk ratio for 53-82 years old

Grade 2 prescription (cancer vs no cancer) Grade 3 prescription (cancer vs no cancer)

Risk ratio for 18-52 years old

Risk ratio for 53-82 years old

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5

5,0

5,5

6,0

-12 -6 0 6 12 18 24

months since cancer diagnosis

Does gender and/or age effect exist ????

To estimate factors associated with a monthly grade II/III analgesic

prescription, we calculated Adjusted Odds Ratios (AOR) by logistic

regression including seven patient characteristics :

1. age in 2010 (year of cancer diagnosis for all cases),

2. gender,

3. has purchased grade II or grade III precribed analgesics medication 6-12

months before cancer diagnosis (Yes/No),

4. has purchased precribed psychotropics medication 6-12 months before

cancer diagnosis (Yes/No),

5. pre-diagnosis somatic multimorbidity score,

6. carstairs index of the place of residence,

7. cancer progression two years after cancer diagnosis (Yes vs No).

Last month analgesic drugs prescription two years after cancer diagnosis...……………………………………1

Limitation to three tumor sites ????

Regarding VICAN survey sampling, we choose tumor sites with

1. Available data for patients from 18 to 82 years old at diagnosis

2. High level of incidence in France

3. N= 4 831 breast, colorectal, head and neck or lung cancer survivors)

Results ????

457 (9.4%) cancer survivors purchased a prescribed analgesics

medication during the previous month. 304 (6.2%) Grade II

122 (2.5%) Grade III

31 (0.6%) both Grade II and Grade III.

Last month analgesic drugs prescription two years after cancer diagnosis...……………………………………2

Last month analgesic drugs prescription two years after cancer diagnosis...……………………………………3

0---1---2---3----------------------------------23------24 month Cancer Year 2

diagnosis

Prescribed analgesics medication purchases by two years cancer

survivors, recorded the previous month (Yes vs No)

p value AOR CI[95%]*

GENDER 0.001

Male (REF) -1-

Female 0.69 [0.56-0.85]

AGE at diagnosis 0.081

18-64 (REF) -1-

>64 0.79 [0.61-1.02]

*CI, calculated using a stepwise logistic regression.

Other variables initially introduced into the model : -analgesics purchases recorded six months before cancer

diagnosis (Yes vs No), psychotropics purchases recorded six months before cancer diagnosis (Yes vs No), cancer

progression two years after cancer diagnosis (Yes vs No), pre-diagnosis somatic multimorbidity score, carstairs index

of the place of residence.

Purchases recorded

SNIIR-AM

Pain experienced the 2 previous weeks among cancer survivors 2 years after diagnosis (Vican 2, 2012)..

44.5%

52.3%

42.3%

36.4%

36.4%

46.3%

44.8%

37.3%

27.1%

30.7%

22.7%

18.2%

27.8%

19.6%

0% 50% 100%

Breast cancer

Colorectal cancer (women)

Colorectal cancer (men)

Lung cancer (women)

Lung cancer (men)

Head and Neck (women)

Head and Neck (men)

Pain without neuropathic characteristics

among women

among men

Pain with neuropathic characteristics

among women

among men

Thank You.....