Medical World News: Clinical/Managed Care Updates

Sarcopenia and Inflammation Associated With Increased Risk of Death in Patients With CRC

Jaime Rosenberg

Prediagnosis inflammation was associated with at-diagnosis sarcopenia (low skeletal muscle mass), and the combination of the 2 nearly doubled the risk of death in patients with nonmetastatic colorectal cancer (CRC), according to a study published in JAMA Oncology.

Sarcopenia and an elevated neutrophil-to-lymphocyte ratio (NLR, a measure of systematic inflammation), have been increasingly recognized as 2 novel prognostic indicators across cancer types, according to the authors. Sarcopenia can be used to predict adverse outcomes such as poor surgical outcomes, treatment toxicity effects, and reduced survival. Similarly, NLR values are utilized to predict treatment response.

“Whereas both sarcopenia and inflammation can be evaluated with existing clinical data and may be modifiable, the relationship between these 2 factors and their independent associations with survival are not well studied,” the authors wrote.

The authors studied 2470 patients from the Colorectal Cancer: Sarcopenia, Cancer, and Near-term Survival (C SCANS) cohort, which included Kaiser Permanente Northern California (KPNC) health plan members who were diagnosed with stage I to III CRC between 2006 and 2011. All participants underwent surgical resection and had abdominal computed tomography (CT) scans at diagnosis.

Using the scans, the authors measured skeletal muscle index. Sarcopenia was defined as less than 52 cm2/m2 for normal or overweight men and less than 38 cm2/m2 for normal or overweight women, and less than 54 cm2/ m2 and less than 47 cm2/m2 for obese men and women, respectively.

Systematic inflammation was measured by NLR from routine blood tests, and the authors averaged all available NLR measures from the 24 months prior to diagnosis. The mean number of NRL measures was 3, and was characterized using standard cut-offs to define normal inflammation as less than 3, moderate inflammation as 3 to less than 5, and high inflammation as 5 or higher.

The results showed that patients with a higher NLR in the 24 months prior to their diagnoses had less favorable values for all other markers of systemic inflammation: higher platelet-to-lymphocyte ratio, lower lymphocyte-to-monocyte ratio, and lower serum albumin level.

The prevalence of an NLR of 3 or greater and sarcopenia were 46% (n = 1133) and 44% (n = 1078), respectively. Over a median of 6 years of follow- up, there were 656 deaths, 357 of which were from CRC. Increasing NLR was associated with sarcopenia in a dose-response manner: compared with patients with NLR of less than 3, the odds ratios (ORs) for sarcopenia were 1.35 (95% CI, 1.10-1.67) for NLR of 3 to less than 5 and 1.47 (95% CI, 1.16- 1.85) for NLR of 5 or greater (P for trend across categories, <.001).

Results also showed that an NLR of 3 or greater and sarcopenia independently predicted overall and CRC-related death. Patients with both sarcopenia and an NLR of 3 or greater had a double the risk of death overall (HR, 2.12; 95% CI, 1.70- 2.65) and CRC related death (HR, 2.43; 95% CI, 1.79-3.29).

“Both sarcopenia and high NLR were independent prognostic indicators in nonmetastatic CRC,” the authors concluded. “If our findings are confirmed by additional studies, these 2 biomarkers are already collected in routine care and thus have high potential for use in clinical prognostication.”

References:

Cespedes Feliciano E, Kroenke C, Meyerhardt J, et al. Associated of systematic inflammation and sarcopenia with survival in nonmetastatic colorectal cancer: results from the C SCANS study. JAMA Oncol. 2017;3(12):e172319. doi:10.1001/jamaoncol.2017.2319.

The Impact High OOP Costs Have on Patients Filling Prescriptions for Oral Cancer Drugs

Laura Joszt, MA

Patients with cancer may have more options for oral cancer medica- tions, but high out-of-pocket costs still present a barrier to access, according to a new study in Journal of Clinical Oncology.

Researchers reviewed claims from 2014 to 2015 from a large, proprietary, integrated database that included Medicare and commercial insurance enrollees for 38 oral anticancer agents. They looked at claim reversal (patients failing to purchase an approved prescription), delayed initiation, and abandonment.

The overall abandonment rate was 18% and rates of claim reversal ranged from 13% to 67% depending on the out-of-pocket (OOP) costs. The study found that 10% of patients who had to pay less than $10 did not pick up their prescription, while 32% of those who had to pay between $100 and $500 and nearly 50% of those who had to pay more than $2000 did not pick up their prescription.

“Patients in our study were facing a new cancer diagnosis or a change in their disease that required a new treatment. Imagine leaving your doctor’s office with a plan, ready to start treatment, only to find you can’t afford it,” lead author Jalpa A. Doshi, PhD, a professor in the Perelman School of Medicine at the University of Pennsylvania, and director of Value-Based Insurance Design Initiatives at the Leonard Davis Institute’s Center for Health Incentives and Behavioral Economics, said in a statement. “It adds more stress at what is already a stressful and scary time.”

The researchers also found that the relationship between high OOP costs and patients not filling their prescriptions was consistent across cancers, even for those that have treatments that significantly extend life. Patients with high OOP costs who did fill their prescriptions were more likely to delay it. With oral drugs, more of the medication’s cost is passed to the patient and complete payment is due upfront, which increases the risk of delayed access or abandonment.

The authors determined that if patients currently paying between $50 and $100 for prescription were bumped up to a higher cost category and were responsible for $100 to $500 instead, that the abandonment rates would actually double.

“This shows the importance of discussing financial barriers up front, during conversations about treatment options, even with patients who don’t raise concerns,” Doshi said. “Patients may not be aware of how expensive their prescriptions will be, and physicians may not realize that a patient has opted not to fill the prescription.”

References:

Doshi JA, Li P, Huo H, Pettit AR, Armstrong KA. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. 2018;36(5)476-482. doi:10.1200/ jco.2017.74.5091.

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