Oncology Transition Study

Tracking Care Patterns by Cancer Site

By Morgan Atkins and April Adams

Earlier this year, members of the Stratasan team conducted a study to determine if treatment care patterns differ for oncology patients by cancer site. The hypothesis was that the most common treatment path for cancer patients is to first seek surgical treatment, then medical, then radiological. Patients were grouped by their order of transition from surgical, medical, and radiological procedures. 

Below you will find the results of this study.

Our Methodology:

Stratasan’s All-Payer Claims Database was used to analyze patients in the state of Florida between Oct 2015 - June 2020 who had a cancer diagnosis of breast, colorectal, brain/spine, gynecologic, thoracic/lung, or skin. The total patient population analyzed equaled 632,923. Those patients were then grouped by each new Treatment Procedure Category (TPC) in chronological order to determine if event transitions between procedure categories differ by cancer sites. 

Key Findings:

Overall Treatment

What is the most common treatment combination?

• 78% of cancer patients receive surgical treatment only - no medical or radiological treatments

Initial Treatment

What is the initial TPC by cancer site?

• 84% of cancer patients receive surgical treatment initially, 9% receive medical, 7% receive radiological
• Thoracic / Lung has the most variance in patient initial treatment procedure
• Only 44% receive surgical treatment initially (compared to 84% for all sites)
• Thoracic has the highest percentage of patients receiving radiological treatment initially, with 28%; 4x the overall percent
• Thoracic has 3x the percent of patients receiving medical treatment, with 27%
• Brain / Spine has a higher proportion of patients receiving radiological treatment initially, with 19%
• Colorectal has 14% of patients receiving medical treatment initially

Diagnosing Physician

Which specialties are diagnosing cancer?

• 33% of the cancer sites are diagnosed by a Primary Care Provider (PCP)
• 66% of Gynecologic is diagnosed by PCP
• 58% of colorectal cancer is diagnosed by a gastroenterologist
• Brian / Spine had the most variance in diagnosing specialties
• 14% diagnosed by endocrinologists
• Surgery and neurosurgery each diagnose 9%
• ENT diagnoses 8%
• Thoracic / Lung also had variance
• 15% diagnosed by pulmonary disease
• 13% by hematology & oncology
• 12% by thoracic surgery
• Emergency Medicine diagnoses 5% of Gynecologic

ER Visit

How many cancer patients come through the ER within a month of cancer diagnosis?

• 9% of cancer patients have an ER visit within 29 days of cancer diagnosis

Key Definitions:

Population Studied:

• Dataset: Stratasan’s All-Payer Claims Database (APCD)
• Geography: Florida
• Timeframe: Oct 2015 - June 2020
• Code Type: ICD-Dx
• Cancer Diagnoses
• Site of Cancer: breast, colorectal, brain/spine, gynecologic, thoracic/lung, skin
• All patients analyzed together as a group and by site of cancer
• Total patients analyzed: 632,923

Treatment Procedure Categories (TPC): 

• Code Type: CPT/HCPCS
• Included Codes:
• Type of Procedures: Surgical, Medical, Radiological
• See below for a breakdown of TPC definitions
• Claims with non-cancer related procedures were discarded from analysis

Findings 1

Most Common Treatment Paths:

• For patients that went to three different* TPCs, the most common path for all cancer sites—breast, gynecologic, and colorectal—was to begin with surgical treatment, then transition to medical, and finally radiological. 
• However, the most common treatment path for thoracic/lung, brain/spine, and skin was surgical first, then radiological, then medical.

*most patients did not receive all three procedure categories

Summary:

Most common treatment path for All Sites, Breast, Gynecologic, Colorectal: 

Surgical → Medical → Radiological

Most common Treatment Path for Thoracic/Lung, Brain/Spine:

Surgical → Radiological → Medical

Findings 2

Initial Procedure Category:

Initial Procedure Category is the first treatment type received post-cancer diagnosis.

• 84% of all cancer patients had surgical treatment initially
• Gynecologic and Skin cancer patients have a stronger percentage initially starting with surgical treatment
• 14% of colorectal patients are initially treated medically
• Thoracic / Lung cancer has 4x the percentage of patients initially treated radiologically than all sites combined, with 28%
• It has 3x the percentage treated medically initially, with 27%
• It has the lowest percentage of patients initially treated surgically
• Brain / Spine also has a significant amount of patients initially treated radiologically, with 19%

Findings 3

Diagnosing Specialist Seen Prior to Surgical Oncology Procedures 

Stratasan analyzed patients who sought surgical treatment initially to see which specialists are typically diagnosing the patients prior to their surgical procedure. The purpose of this portion of the analysis was to determine which specialists refer into surgical oncology and if the specialists differ by cancer site.

Note: Several claims list radiologists, pathologists, or mid-levels as the rendering provider and have a referring physician listed as well. In those circumstances, the rendering provider was replaced with the referring physician under the assumption that the referring physician orders the imaging or lab, etc and diagnoses the patient. For example, several claims list a diagnostic radiologist as the rendering physician with an internal medicine physician as the referring. 

• 26% of all patients are diagnosed by a primary care practitioner (PCP), regardless of cancer site
• PCP includes: internal medicine, family practice, nurse practitioner, physician assistant, OB/GYN (with no sub-specialty); see appendix
• Gynecologic has the largest amount of diagnoses by PCP with 66% 
• Colorectal cancer has fewer cases diagnosed by PCP
• Gastroenterology diagnoses 58% of colorectal cancer
• Surgery diagnoses a higher proportion of breast cancer, with 32% 
• Surgery accounts for 6% of all cancer diagnoses
• Brain / Spine has several specialties that have a higher rate for diagnosing than other cancer sites 
• Endocrinologists diagnose 14%, compared to only 1% for all sites
• Neurological surgery and surgery diagnose 9% each
• Otolaryngology accounts for 8% of all diagnoses, compared to 1% for all cancer sites
• Thoracic / Lung also has a varied amount of specialists diagnosing at a higher rate
• Pulmonary disease diagnoses 15%
• Hematology/oncology diagnoses 13%
• Thoracic surgery diagnoses 12%

The table below displays the proportion of specialists diagnosing by cancer site.

Findings 4

Emergency Visit Prior to Diagnosis

Summary:

• 9% of all cancer patients had an ER visit within 29 days of diagnosis; this equals about 32k patients
• Brain / Spine, Gynecologic, and Thoracic / Lung have the highest rate (12-13%) of patients seen in the ER within 29 days of cancer diagnosis

** This table includes patients who went to the ER the same day of their cancer diagnosis

ER Diagnosis Product Line:

Stratasan compared the distribution of diagnosis products lines of all ER patients and ER patients who were diagnosed w/ cancer within 29 days of ER visit.

• Less than 1% of all ER patients receive an oncology/hematology diagnosis in the ER
• However, 18% of cancer patients that had an ER visit within 29 days are diagnosed in the ER
• Gynecology patients are most likely to receive their cancer diagnosis in the ER, with 26%
• The second-most common diagnosis for gynecology is gastroenterology

Time Between ER visit and Cancer Diagnosis:

• Gynecologic patients are the most likely to receive their diagnosis in the ER
• They represent over 50% of same-day diagnoses

Findings 5

Radiological Procedure Detail

Overall:

Analyzed patients that had radiological treatment at any point:

• Total amount of patients: 78,692
• IMRT is the leader of radiological treatments and accounts for 28%
• Conventional External Beam Radiation accounts for 26% of all radiation treatment

Findings 6

Medical Procedure Detail

Overall:

Analyzed patients that had medical treatment at any point:

• 88% of medical treatments are for chemotherapy
• 9% of skin cancer medical treatments are photodynamic therapy
• Gyn has the largest percentage of transfusions, with 12%

• Total amount of patients receiving medical treatment: 82,745
• Brain / Spine:  5%
• Breast:  19%
• Colorectal:  33%
• Gyn:  9%
• Skin:  16%
• Thoracic / Lung:  18%

Findings 7

Gyn Cancer Patient Detail

Summary:

• 20% between ages 45-54
• 59% commercially insured

Findings 8

Care Setting for Surgical Procedures by Cancer Site

Overall:

• 44% of surgical procedures are performed in the hospital outpatient care setting
• 62% of breast procedures are performed in the hospital outpatient care setting
• Thoracic / Lung has the highest percentage of procedures performed in the inpatient care setting with 27%
• Brain / Spine has 22% of surgical procedures performed in the inpatient care setting
• Gyn has the highest percentage of surgeries performed in the office care setting, with 31%

Gyn:

• Diagnoses referencing a leiomyoma of uterus have a higher proportion of surgeries performed in the office care setting
• All four of the codes referencing leiomyoma of uterus in the top 10 diagnoses have over 30% of surgeries performed in the office care setting
• The three codes in the top 10 with “malignant neoplasm” in the description have a higher rate of procedures performed in the inpatient care setting
• All three codes have over 19% in the inpatient setting
• Malignant neoplasm of endometrium has the lowest proportion of procedures performed in the office setting, with only 8%

Key Takeaways

With access to clean APCD, the opportunities for analysis are endless. Equipped with this intelligence, planning teams can evaluate opportunities to grow business, build new facilities, acquire practices, recruit physicians, and add service lines. To learn more about the insights and referral patterns that can be gathered from Strasan’s APCD, contact our team and schedule a discovery call today.

Study conducted by Morgan Atkins, VP of Product and Innovation and April Adams, Data Scientist for Stratasan

Appendix

Treatment Procedure Category Definition:

Primary Care Specialty Definitions:

Family Medicine
Family Medicine: Adult Medicine
General Practice
Internal Medicine
Nurse Practitioner
Nurse Practitioner: Adult Health
Nurse Practitioner: Family
Nurse Practitioner: Obstetrics & Gynecology
Nurse Practitioner: Primary Care
Nurse Practitioner: Women's Health
Obstetrics & Gynecology
Obstetrics & Gynecology: Gynecology
Obstetrics & Gynecology: Obstetrics
Pediatrics
Physician Assistant
Physician Assistant: Medical

Treatment Path:

• How patients transition through the TPC
• Including of the patient’s TPC of the three subsequent events
• Repeat TPC’s are not counted
• Patients who do not transition to a different TPC are grouped together

Event Transition:

• When a new TPC is identified for an oncology patient 

Example #1:

• If a patient goes from Surgical → Medical → Surgical → Medical → Radiological
• Treatment Path = Surgical → Medical → Radiological

Example #2:

• If a patient goes from Surgical → Surgical
• Treatment Path = Surgical → None → None
• New claims with the same Treatment Procedure Category does not count as a transition
• Patients that do not transition to a new category are assigned “None” as a TP