The Time Toxicity of Cancer Treatment

Dr. Arjun Gupta, a GI medical oncologist at the University of Minnesota Masonic Cancer Center in Minneapolis, speaks with host Dr. John Sweetenham, associate director for Clinical Affairs at UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center, about the concept of time toxicity in cancer treatment. Dr. Gupta proposes a measure of time toxicity and a framework for how it could be implemented in research and clinical practice.   Transcript Dr. John Sweetenham: Hello, I'm John Sweetenham, the Associate Director for Clinical Affairs at UT Southwestern Harold C. Simmons Comprehensive Cancer Center, and host of the ASCO Daily News podcast. I'm delighted to welcome Dr. Arjun Gupta to the podcast today. He's an assistant professor and gastrointestinal medical oncologist at the University of Minnesota Masonic Cancer Center in Minneapolis. We'll be discussing the concept of time toxicity and its relevance for patients with cancer, especially those with advanced cancer who face treatment decisions in the context of limited time. Dr. Gupta will share his insights on how to measure time toxicity and discuss a framework for how it could be implemented in research and in clinical practice. My guest and I have no conflicts relating to our topic today. Our full disclosures are available in the show notes and disclosures of all guests on the podcast can be found on our transcripts at asco.org/podcasts. Dr. Gupta, it's great to have you on the podcast today. Dr. Arjun Gupta: I'm an avid listener of the podcast. It's a joy to be here. Dr. John Sweetenham: Thank you. It's a joy to have you on the podcast as well. We're particularly pleased to have you discuss this important topic that you and your co-authors addressed recently, in your commentary in the Journal of Clinical Oncology. Can you first explain the concept of time toxicity, particularly as it relates to cancer treatment? Dr. Arjun Gupta: Yes, we conceptualize time toxicity as the time spent in pursuing a treatment for cancer. Now, this includes time spent in coordinating treatments, in travel to treatments, in waiting rooms, in actually getting that treatment, in getting anticipated and unanticipated adverse events, follow up tests and rehabilitations, frequent visits to a health care facility, all of this time that a patient and their care partner are spending is what we think of as time toxicity. This concept of time toxicity is perhaps applicable to all patients but is perhaps most applicable to people with advanced solid tumors, who are facing treatment decisions in the context of limited time. And in some cases, the overall survival benefit, or the time benefit offered by treatment may actually be overtaken by the time spent in pursuing that treatment. So, that's how we came up with this concept of time toxicity. Dr. John Sweetenham: Thanks. In your article, you propose a measure of time toxicity provides a framework for how it could be implemented in research and in routine clinical practice. Can you tell us a little more about this? Dr. Arjun Gupta: The measure we describe and propose is days with physical health care system contact. This is the measure of time toxicity that we propose. So any day in which a patient has any contact with the health care system, whether that be for a 30-minute blood draw, whether that be for a 3-hour procedure, whether that be for a 6-hour chemotherapy infusion, a 12-hour visit to the urgent care center, or an overnight stay is treated the same. It's a day with physical health care system contact. And we recognize that not all of these are the same but for the patient and their care partner, these often represent that an entire day is lost. As a corollary, days not spent with health care contact are home days. So, in essence, your overall survival or the time from diagnosis to death is nothing but the sum total of time toxicity or days with health care system contact and home days. Now me and my mentors, Dr. Chris Booth, and Dr. Elizabeth Eisenhower spent a lot of time thinking about whether we should propose a metric at all, or wait for the science to be advanced even more. But there are a couple of reasons we decided to go forward and propose this metric. Even though there are some deficiencies that I'll come to. First of all, this metric recognizes that oncology care is delivered in multiple settings. It's delivered infrequent trips to the outpatient clinics and infusion centers, and patients often require inpatient admissions for rest and rehabilitation. My mentors, Dr. Chris Booth and Dr. Elizabeth Eisenhower, and I discussed long and hard whether we wanted to propose a metric or wait for the science of time toxicity to progress. Ultimately, we decided to propose this metric because it's practical and can easily be measured. It is patient-centered, which is perhaps the most important thing. And third, it recognizes that cancer care is delivered in multiple settings, both inpatient and outpatient. There are a couple of things that we need to keep in mind while thinking about this metric. The first is that people with cancer are often sick because of underlying cancer and cancer care and physical health care system contact by itself is not a bad thing. So, we need to separate the additional time imposed by a specific cancer treatment over and above the time toxicity of cancer itself, and we also need to keep in mind that this metric has some limitations in that decreased health care contact or decreased time toxicity could represent poor access to care and could widen disparities in health care access. Furthermore, care is increasingly being delivered in the home of patients. And while that may decrease time toxicity, and may be more comfortable for certain families, for unprepared families, this may be very burdensome. So, we recognize that this metric is not perfect but we hope that this can at least start conversations about time toxicity, to fulfill our ultimate goal for clinical trials to actually report time toxicity alongside more traditional endpoints. Dr. John Sweetenham: Yes, I think one of the things that really struck me from reading your commentary was the fact that of course, for a patient, a 1-hour or 30-minute trip to the laboratory for a blood draw can disrupt the whole day. And in many respects, that can be as disruptive as spending 12 hours in the emergency room from a family and caregiver perspective that really kind of sank home with me, I must say, having read the commentary. On that note, you know, could you give us some specific examples to show how time toxicity negatively impacts patients? Dr. Arjun Gupta: Yes, so for a couple of trials that we described in the paper, we demonstrated that the time toxicity associated with pursuing the treatment was actually more than the average survival benefit offered by the treatment. Now we have to keep in mind that traditionally, oncology clinical trials don't report time toxicity. So, this was my co-authors and myself getting together and getting a best-case scenario from clinical trial publications. But as an example, for people with advanced biliary tract cancers, or cholangiocarcinoma, in the second line, there was a recent trial that demonstrated that FOLFOX chemotherapy, on average, improved survival by 27 days. And we demonstrated through the trial level publication, that for the average patient who was getting the average number of chemotherapy doses, coming in for blood work, coming in for scans, coming in for oncology assessments, that for the average patient, the time toxicity was more than this 27-day benefit, it was 30 days. And so, this is a very clear example of a patient who potentially loses more time than what they gain. It's very important to recognize that patients may value these decisions differently, and we're not saying that this treatment is bad or should not be pursued. People have different values, and we should explore that, but the biggest issue right now is that oncologists don't have the data from clinical trials to even have these conversations with patients. Dr. John Sweetenham: Thanks. And so, I'll pick up on that point. Obviously, the literature is very full of studies that have looked at oncologists and their skills for wanting a better word at having the end-of-life discussions and goals of care discussions with their patients. Do you sense that there is or will be a reluctance on the part of oncologists to have these kinds of conversations about time toxicity for patients who may be nearing the end of their lives? Dr. Arjun Gupta: I don't think so at all. I will share that I've become much more humble since I've become an oncologist myself, and I've become less critical of oncologists. I think our jobs are incredibly difficult. And most, if not all, oncologists want to do the right thing and have these conversations. The 2 things that are missing right now are data. So, we just don't have the data, which is why we wrote this commentary as a call for clinical trials to report this. And the second is our own time toxicity or delay limitation of time in the clinic. A wise person recently said that the biggest technological advance in medicine will be more time with patients. So, I think we need more data on time toxicity and we need more time for ourselves with patients to have these conversations to help them reach the best decision for their own goals and values. Dr. John Sweetenham: Are there any other key takeaways that you would like to share with our listeners today? Dr. Arjun Gupta: I feel—yes. As the next steps, our team is looking at doing secondary analyses of completed clinical trials to show that using this metric of days with physical health care contact is feasible, even in the secondary analysis of clinical trials. While we advocate for this to be included prospectively in clinical trials. It's very important to note that in retrospective work, looking at time toxicity, we remember that the time toxicity of a treatment retrospectively represents not just the treatment itself, but the entire health care delivery system, and social determinants of health. So, we shouldn't get too far ahead of ourselves in interpreting treatments against each other. But that perhaps offers us an opportunity to look internally at ourselves and add our processes to see how we can improve. Lastly, there are several quality improvement initiatives going on to reduce time toxicity for patients, such as triage, and decreasing waiting room times, and we should perhaps advocate for and promote such work more broadly. Dr. John Sweetenham: Thanks so much, Dr. Gupta, for coming on to the podcast today and for sharing your thoughts on a subject, which I'm sure is going to be something that will provoke a lot of discussions and will make many of us think harder in the future. And we look forward to seeing your ongoing research in this area. Dr. Arjun Gupta: Thank you for this platform. Dr. John Sweetenham: Thank you to our listeners for your time today. If you're enjoying the content on the ASCO Daily News podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.   Disclosures: Dr. John Sweetenham: Consulting or Advisory Role: EMA Wellness Dr. Arjun Gupta: None disclosed.   Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO the mention of any product or service organization activity or therapy should not be construed as an ASCO endorsement.