{"product_id":"time-spent-receiving-cancer-care-why-it-matters-for-patients-with-prostate-bladder-kidney-and-testicular-cancers","title":"Time Spent Receiving Cancer Care: Why It Matters for Patients with Prostate, Bladder, Kidney, and Testicular Cancers","description":"\u003cp\u003eThis review examines \"time toxicity\" in people with genitourinary (GU) cancers such as prostate, bladder, kidney, and testicular cancer. Time toxicity is the time patients spend receiving cancer care, including clinic visits, laboratory tests, imaging, travel, and urgent care for complications. The authors identified 22 relevant studies. The authors found that time toxicity has been studied extensively in other cancer types but rarely in GU cancers. This is despite the many life-prolonging treatments now available for these patients. The review describes methods for measuring time toxicity. The review summarizes findings from non-GU cancer studies. The review calls for dedicated research in GU cancer populations to help patients and doctors make better treatment decisions.\u003c\/p\u003e\n\n\u003ch1\u003eTime Spent Receiving Cancer Care: Why It Matters for Patients with Prostate, Bladder, Kidney, and Testicular Cancers\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eBackground: What Is Time Toxicity and Why Does It Matter?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#gu-cancers\"\u003eWhy Genitourinary Cancers Are Important for Studying Time Toxicity\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#methods\"\u003eHow This Review Was Conducted\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#quantifying\"\u003eHow Researchers Measure Time Toxicity\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#contact-days\"\u003eThe Contact Days Method: Simple and Widely Used\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#mixed-methods\"\u003eMore Detailed Approaches to Measuring Time Toxicity\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ideal-method\"\u003eWhat the Ideal Measurement Method Looks Like\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#non-gu-studies\"\u003eWhat Studies in Other Cancers Have Found\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#detailed-findings\"\u003eDetailed Findings from Non-GU Cancer Studies\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#clinical-implications\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of Current Research\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations and Future Directions\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eTime toxicity is the time patients spend in healthcare contact, including visits, tests, imaging, travel, and care for complications.\u003c\/li\u003e\n\u003cli\u003eGenitourinary cancers include prostate, bladder, kidney, and testicular cancers; many new treatments help patients live longer but require significant time.\u003c\/li\u003e\n\u003cli\u003eThe contact days method counts days with any physical healthcare encounter as time away from home; it is simple but may over- or underestimate time.\u003c\/li\u003e\n\u003cli\u003eStudies in other cancers show time toxicity varies by treatment; for example, in one trial, median contact days were 28 with cetuximab versus 10 with supportive care.\u003c\/li\u003e\n\u003cli\u003eThe authors call for dedicated research in genitourinary cancers to help patients and doctors make better treatment decisions.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eBackground: What Is Time Toxicity and Why Does It Matter?\u003c\/h2\u003e\n\n\u003cp\u003ePatients with genitourinary (GU) cancers — which include cancers of the prostate, bladder, kidney, and testis — make up a large group of cancer survivors worldwide. These patients have very different outcomes. Some have a good prognosis, while others face a high risk of illness and death. Many patients receive multiple rounds of treatment over time.\u003c\/p\u003e\n\n\u003cp\u003eIn the past decade, researchers have developed many new treatments that help patients with GU cancers live longer. However, these treatments also require significant time commitments from patients. This has led to growing interest in a concept called \u003cstrong\u003etime toxicity\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eTime toxicity refers to the time patients spend in contact with the healthcare system. This includes:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eClinic visits for evaluation and treatment\u003c\/li\u003e\n  \u003cli\u003eLaboratory tests and imaging studies\u003c\/li\u003e\n  \u003cli\u003eTime spent addressing complications from the disease or its treatment\u003c\/li\u003e\n  \u003cli\u003eOutpatient and inpatient care\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThis time spent on healthcare activities can significantly reduce the value of the extra survival time gained from treatment. For patients with advanced cancer, whose remaining time may be limited, this trade-off is especially important. Patients and their caregivers at any point in their cancer journey can end up investing a substantial amount of their day receiving cancer care. This often comes at the cost of time otherwise spent at work or doing personal activities.\u003c\/p\u003e\n\n\u003cp\u003eThe first studies of time toxicity focused mainly on patients with advanced solid tumors. There has been a surprising lack of research examining time spent with healthcare contact in patients with GU cancers specifically.\u003c\/p\u003e\n\n\u003ch2 id=\"gu-cancers\"\u003eWhy Genitourinary Cancers Are Important for Studying Time Toxicity\u003c\/h2\u003e\n\n\u003cp\u003eGU cancers offer an excellent opportunity to study the impact of time toxicity. In the past decade, patients with these cancers have seen the development of multiple life-prolonging treatments. These treatments may be used in the same clinical setting but may have very different impacts from a time toxicity perspective. This can influence treatment decision-making.\u003c\/p\u003e\n\n\u003cp\u003eConsider the recently approved combination of \u003cstrong\u003eenfortumab vedotin and pembrolizumab\u003c\/strong\u003e for patients with advanced bladder cancer. This combination has transformed the standard of care. However, the treatment plan has an indefinite duration. It also can cause side effects such as \u003cstrong\u003eneuropathy\u003c\/strong\u003e (nerve damage that can cause pain, numbness, or weakness). These side effects may require additional visits and supportive measures over time.\u003c\/p\u003e\n\n\u003cp\u003ePatients may need to consider whether to pursue treatment with these medications indefinitely until the cancer progresses, or to pause treatment at a point of acceptable disease control. They may compare this option with a more consolidated treatment course of chemoimmunotherapy.\u003c\/p\u003e\n\n\u003cp\u003eSimilarly, the approval of \u003cstrong\u003e177Lutetium-PSMA-617\u003c\/strong\u003e for metastatic castrate-resistant prostate cancer (mCRPC) may offer prolonged disease control to a subset of patients. However, this treatment comes at the expense of increased laboratory and imaging monitoring. Patients also need to travel to tertiary care cancer centers to receive this therapy. Additionally, there is a required period of separation from loved ones for the days immediately following treatment.\u003c\/p\u003e\n\n\u003cp\u003eThe purpose of this review is to summarize the rapidly growing study of time toxicity in cancer. The authors place particular emphasis on its potential applications in supporting shared decision-making among patients with GU malignancies.\u003c\/p\u003e\n\n\u003ch2 id=\"methods\"\u003eHow This Review Was Conducted\u003c\/h2\u003e\n\n\u003cp\u003eThe authors performed a targeted search of peer-reviewed publications in publicly available journal databases. These databases included MEDLINE and Embase. The search covered the period from April 2016 up to July 2024.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers used keywords such as:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\"Time toxicity\"\u003c\/li\u003e\n  \u003cli\u003e\"Contact days\"\u003c\/li\u003e\n  \u003cli\u003e\"Home time\"\u003c\/li\u003e\n  \u003cli\u003e\"Healthcare contact\"\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThey also searched for terms related to GU malignancies, including \"prostate cancer,\" \"kidney cancer,\" \"bladder cancer,\" \"testicular cancer,\" and related cancer-specific terms. The authors identified \u003cstrong\u003e22 relevant studies\u003c\/strong\u003e that were included in this review.\u003c\/p\u003e\n\n\u003cp\u003eSince the majority of studies on time toxicity have equated it with time spent with healthcare contact, these two terms are used interchangeably throughout the review. However, the authors recognize that there are many ways time may be indirectly dedicated to cancer care and its complications that do not qualify as healthcare contact. These additional ways are discussed in the review.\u003c\/p\u003e\n\n\u003ch2 id=\"quantifying\"\u003eHow Researchers Measure Time Toxicity\u003c\/h2\u003e\n\n\u003cp\u003eClinical trials offer reliable information on the expected likelihood and length of cancer control and rates of adverse effects. However, there is little definitive information describing the time investment associated with receiving cancer therapies.\u003c\/p\u003e\n\n\u003cp\u003eAt best, patients receiving treatments administered in clinical settings have predictable schedules for the days that require treatment or associated supportive care. However, these estimates rarely quantify several important factors:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eThe need for monitoring with laboratory studies and imaging\u003c\/li\u003e\n  \u003cli\u003eTravel time to and from healthcare settings\u003c\/li\u003e\n  \u003cli\u003eThe likelihood of additional healthcare interactions related to complications from cancer or its treatment\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThese complications can force patients to seek urgent medical care. In addition, patients who live a significant distance away from healthcare institutions may need to dedicate more time to receive the same care than those who reside in urban areas.\u003c\/p\u003e\n\n\u003ch2 id=\"contact-days\"\u003eThe Contact Days Method: Simple and Widely Used\u003c\/h2\u003e\n\n\u003cp\u003eThe earliest proposed method for evaluating time spent in versus out of healthcare settings by cancer patients receiving therapy was the \u003cstrong\u003eQuality-adjusted Time Without Symptoms or Toxicity (Q-TWiST)\u003c\/strong\u003e measure. As the name suggests, Q-TWiST characterizes the time that patients spend with and without symptoms from cancer and\/or treatment. It does this by incorporating adverse event rates and survival data from clinical trials.\u003c\/p\u003e\n\n\u003cp\u003eQ-TWiST was conceived in the late 1980s to supplement traditional clinical outcomes. It laid the groundwork for the current interest in time toxicity. Q-TWiST rapidly gained popularity across a variety of cancer and non-cancer settings, including in GU populations. However, it mostly remains a research methodology. It requires an equation using utility coefficients to determine the quality time trade-offs. This limits its accessibility by unfamiliar clinicians and patients.\u003c\/p\u003e\n\n\u003cp\u003eIn the development of time toxicity as an outcome, a number of mechanisms have been proposed for best measuring time spent with healthcare contact. The most pragmatic, intuitive, and widely adopted method involves separating days with and without physical healthcare contact. These are labeled as \u003cstrong\u003e\"contact days\"\u003c\/strong\u003e or \u003cstrong\u003e\"home days,\"\u003c\/strong\u003e respectively.\u003c\/p\u003e\n\n\u003cp\u003eAny physical encounters with the health system are considered whole days away from home and thus \"time spent toxic.\" These encounters include:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eAmbulatory clinic visits\u003c\/li\u003e\n  \u003cli\u003eNursing-administered treatments\u003c\/li\u003e\n  \u003cli\u003eAncillary testing\u003c\/li\u003e\n  \u003cli\u003eInpatient level of care\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eTelehealth has rapidly risen and become established as a type of healthcare encounter. This could prompt its inclusion in the contact day model. Arguably, the time commitment for patients is drastically reduced when visits and other discussions occur through virtual methods of communication. Thus, currently, only physical encounters are included in this binary contact\/home day model.\u003c\/p\u003e\n\n\u003cp\u003eMost studies have abstracted contact days from electronic medical record systems or trial protocols. Other studies were able to quantify healthcare contact based on medical insurance claims. Some studies have proposed variations of the contact\/home day model. These variations include:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eReporting home days (the inverse of contact days)\u003c\/li\u003e\n  \u003cli\u003eSharing the proportion of contact days with respect to overall survival time\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe adoption of contact days as the preferred method for quantifying time toxicity can be ascribed to its simplicity to quantify and interpret. Some limitations of the contact days method include:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eThe risk of overestimating the time commitment for patients (not every patient encounter involves multiple hours of the day)\u003c\/li\u003e\n  \u003cli\u003eThe risk of underestimating healthcare contact due to confounders (such as decreased appointments due to limited access to care)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"mixed-methods\"\u003eMore Detailed Approaches to Measuring Time Toxicity\u003c\/h2\u003e\n\n\u003cp\u003eAn innovative study suggested an alternate mixed methods approach for quantifying healthcare contact. This study was conducted in patients with metastatic breast cancer. Time receiving cancer-related healthcare was established using data derived from:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eDirect observation of patients in the clinic\u003c\/li\u003e\n  \u003cli\u003ePatient surveys\u003c\/li\u003e\n  \u003cli\u003eAdministrative claims\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eUltimately, cancer care-related time was calculated using an equation. This equation combined:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eTime spent traveling to and from outpatient appointments\u003c\/li\u003e\n  \u003cli\u003eServices received during appointments\u003c\/li\u003e\n  \u003cli\u003eAncillary testing\u003c\/li\u003e\n  \u003cli\u003eInpatient care\u003c\/li\u003e\n  \u003cli\u003eHealthcare-related activities outside of the clinic\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThis method likely offers the most comprehensive and realistic quantification of the time investment required by patients receiving cancer care. However, the multiple steps required through this method can limit its clinical implementation.\u003c\/p\u003e\n\n\u003cp\u003eA subsequent study sought to directly observe time spent on ambulatory care. This study incorporated real-time location badges to track time patients spent in the clinic. It also included estimates of travel times to obtain a total \"home to home\" time. However, this approach ultimately provided a narrower scope of time toxicity than other studies.\u003c\/p\u003e\n\n\u003ch2 id=\"ideal-method\"\u003eWhat the Ideal Measurement Method Looks Like\u003c\/h2\u003e\n\n\u003cp\u003eThe ideal way of determining time spent engaging with healthcare likely involves a combination of approaches. This includes measuring contact versus home days, with a more in-depth characterization of time involvement at each clinical encounter.\u003c\/p\u003e\n\n\u003cp\u003eThe rise of tracking technology and computer-driven algorithms may refine how healthcare contact is collected and computed. Many healthcare systems are using real-time tracking services on patients and providers to improve care delivery. The information gained can also be used to study time toxicity.\u003c\/p\u003e\n\n\u003cp\u003ePersonal devices equipped with tracking technology, such as smartphones or watches, could provide real-world evidence of the time spent in different health settings outside of clinic visits. This includes picking up medications at pharmacies or receiving physical therapy at home.\u003c\/p\u003e\n\n\u003cp\u003eThe aid of patients in capturing time toxicity outside of clinical settings will prove invaluable to derive precise measurements. A sufficiently comprehensive yet intuitive method of assessment is needed by researchers and clinicians. The objective is to precisely quantify time estimates that can be considered in clinical decision-making.\u003c\/p\u003e\n\n\u003ch2 id=\"non-gu-studies\"\u003eWhat Studies in Other Cancers Have Found\u003c\/h2\u003e\n\n\u003cp\u003eThe past 5 years have seen multiple studies evaluating time spent with healthcare contact in patients with cancer. The authors highlighted studies conducted in non-GU populations where time toxicity outcome measures were the primary endpoint, rather than part of a larger healthcare utilization analysis.\u003c\/p\u003e\n\n\u003cp\u003eSeveral studies were able to retrospectively retrieve healthcare contacts using clinical trial protocols and available trial data. These post hoc analyses provide clinically applicable findings by comparing time toxicity between different treatment approaches.\u003c\/p\u003e\n\n\u003cp\u003eIn one analysis, patients with advanced gastroesophageal cancer had significantly fewer contact days if treated with immunotherapy. The median was \u003cstrong\u003e28 days\u003c\/strong\u003e (interquartile range 24 to 41 days). This compared with \u003cstrong\u003e39 days\u003c\/strong\u003e (interquartile range 21 to 51 days) for chemotherapy and \u003cstrong\u003e39 days\u003c\/strong\u003e (interquartile range 30 to 52 days) for chemoimmunotherapy.\u003c\/p\u003e\n\n\u003cp\u003eData derived from trials evaluating a later-line treatment compared to best supportive care can be similarly meaningful. These data help patients with advanced cancer who are interested in the actual time spent at home if they were to forgo treatment.\u003c\/p\u003e\n\n\u003cp\u003eSeveral studies used large population-based datasets to evaluate time toxicity in patients with advanced cancer. These studies compared time toxicity between therapeutic approaches. One study analyzed home time in patients with acute myeloid leukemia using a SEER-Medicare dataset. This study found a higher proportion of home time among patients who received hypomethylating agents compared with patients treated with anthracycline-based chemotherapy (\u003cstrong\u003e60.8% versus 51.9%\u003c\/strong\u003e).\u003c\/p\u003e\n\n\u003cp\u003eA primary advantage of population-based analyses includes the potential for precise estimates of healthcare contact. These estimates are based on linked billing claims data from large populations of patients treated in real-world settings. Moreover, these large datasets allow for covariate analysis. This can identify differences in time toxicity between groups of patients.\u003c\/p\u003e\n\n\u003ch2 id=\"detailed-findings\"\u003eDetailed Findings from Non-GU Cancer Studies\u003c\/h2\u003e\n\n\u003cp\u003eThe review summarized findings from multiple studies across different cancer types. These studies varied widely in size, from 107 patients to 12,378 patients.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePancreatic cancer:\u003c\/strong\u003e In a study of 107 patients with locoregional pancreatic cancer from a single institution, the median time spent receiving care was \u003cstrong\u003e5% of total survival time\u003c\/strong\u003e and \u003cstrong\u003e11% of overall survival\u003c\/strong\u003e. This study provided a comprehensive evaluation of time receiving multidisciplinary care. However, it mixed contact days with hours, which complicates data interpretation. Times spent during appointments and travel were not directly captured.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcute myeloid leukemia:\u003c\/strong\u003e In a study of 113 patients with newly diagnosed acute myeloid leukemia aged 60 or older, the adjusted mean proportion of home days was \u003cstrong\u003e0.67\u003c\/strong\u003e (95% confidence interval: 0.63 to 0.71). There was no significant difference between treatment groups. This study was overall underpowered for subgroup analysis.\u003c\/p\u003e\n\n\u003cp\u003eAnother study of 197 patients with newly diagnosed acute myeloid leukemia aged 60 or older found that the mean home time was \u003cstrong\u003e9.1 months\u003c\/strong\u003e during the first year. Home time improved in the high-intensity treatment group compared with intermediate- and low-intensity treatment groups (\u003cstrong\u003e13.1 versus 5.5 versus 7.6 months\u003c\/strong\u003e). This study captured the evolution of contact days and trade-offs with induction therapies. However, it had insufficient granularity on the type of contact days and their association with patient characteristics.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEarly-phase clinical trials:\u003c\/strong\u003e A study of 219 patients in early-phase clinical trials at a single Australian institution found that the median contact days were \u003cstrong\u003e29% of time alive\u003c\/strong\u003e. There were higher contact days in the first 2 cycles. This study provided helpful characterization of contact days according to study protocol. However, it had limited analysis of the type of contact days.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eMultiple myeloma:\u003c\/strong\u003e In a study of 252 patients with multiple myeloma after autologous stem cell transplant (auto-SCT) from a single institution, \u003cstrong\u003e40% of patients\u003c\/strong\u003e reported time toxicity. Time toxicity was more prevalent in patients on treatment than on surveillance. This study tested for association with financial toxicity and quality of life. It included phone calls as time toxicity, which is not standard. There was no direct quantification of healthcare contact, and there was a risk of recall bias.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eMetastatic cancer:\u003c\/strong\u003e A study of 362 patients with metastatic cancer from a single institution found a median of \u003cstrong\u003e22 encounter days\u003c\/strong\u003e (10% of survival time) and a median visit time of \u003cstrong\u003e4.6 hours\u003c\/strong\u003e. This study used an intuitive outcome and practical findings. The estimated time was derived from electronic medical record localization software. However, it was limited to outpatient encounters.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePhase I\/II clinical trials:\u003c\/strong\u003e A study of 408 patients from phase I\/II clinical trials at a single institution found a mean of \u003cstrong\u003e21.3 contact days\u003c\/strong\u003e (standard deviation 19.74). Contact days were highest during the first month of trial. This study provided insightful multivariable analysis and tested for association with clinical outcomes such as response rate and overall survival. However, it was missing information on the type of contact days.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAmbulatory care time:\u003c\/strong\u003e A study of 435 patients from a single academic institution found that the median total ambulatory time was \u003cstrong\u003e197 minutes\u003c\/strong\u003e. Of this, \u003cstrong\u003e119 minutes\u003c\/strong\u003e were spent in the clinic and \u003cstrong\u003e50 minutes\u003c\/strong\u003e in travel. This study provided accurate time quantification using a tracking system. However, estimates of travel time have limited generalizability.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAdvanced gastrointestinal malignancies:\u003c\/strong\u003e A study of 468 patients in a single Veterans Affairs (VA) institution who died of advanced gastrointestinal malignancies found a median of \u003cstrong\u003e44 contact days\u003c\/strong\u003e, representing \u003cstrong\u003e35% of total survival time\u003c\/strong\u003e. This study graphed contact days to show a \"U-shaped\" trajectory. The population was relatively sick, with over half untreated.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAdvanced colorectal cancer:\u003c\/strong\u003e In a study of 572 patients with advanced colorectal cancer in the CCTG CO.17 trial comparing cetuximab versus supportive care, the median contact days were \u003cstrong\u003e28 with cetuximab versus 10 with supportive care\u003c\/strong\u003e. The median home days were similar (\u003cstrong\u003e140 versus 121\u003c\/strong\u003e). This study provided intuitive and applicable findings. However, the current standard of care has evolved since this trial.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eRelapsed\/refractory large cell lymphoma:\u003c\/strong\u003e A study of 619 patients with relapsed\/refractory large cell lymphoma in the CCTG LY.12 trial comparing GDP versus DHAP found a median of \u003cstrong\u003e18 contact days with GDP versus 19 with DHAP\u003c\/strong\u003e. There were higher home days with GDP (\u003cstrong\u003e33 versus 28\u003c\/strong\u003e). This was an informative and practical study. However, it was unable to determine contact days for consolidation therapy such as auto-SCT.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eStage II or higher melanoma:\u003c\/strong\u003e A study of 731 patients with stage II or higher melanoma in a longitudinal, propensity score-matched Canadian cohort found a median of approximately \u003cstrong\u003e30 contact days\u003c\/strong\u003e in the first year from treatment start. Contact days were higher with stage IV disease. This study included a sensitivity analysis including home care and virtual visits. It had a diverse cohort across years. However, the diversity across cancer stage obscures interpretation of findings, and no raw data were provided.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAdvanced gastrointestinal malignancies:\u003c\/strong\u003e A study of 809 patients with advanced gastrointestinal malignancies from a single institution found that median contact days were \u003cstrong\u003e25.8% of overall survival\u003c\/strong\u003e. Of these, \u003cstrong\u003e83.6%\u003c\/strong\u003e were spent in outpatient care. This study graphed contact days to show a \"U-shaped\" trajectory. However, it provided limited insight into the type of contact days.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOlder cancer survivors:\u003c\/strong\u003e A study of 1,168 cancer survivors aged 65 or older using the Medicare Current Beneficiary Survey linked with Medicare claims data found a mean of \u003cstrong\u003e28.4 contact days\u003c\/strong\u003e (standard deviation 27.6) during one year. Of these, \u003cstrong\u003e64%\u003c\/strong\u003e were not linked with a clinician visit. This study provided subtle characterization of contact days and associated covariates. However, the population was heterogeneous in the survivorship spectrum.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eMetastatic breast cancer:\u003c\/strong\u003e A study of 2,949 patients aged 67 or older from SEER-Medicare with metastatic breast cancer found a mean of \u003cstrong\u003e41 outpatient days\u003c\/strong\u003e (standard deviation 30) within the first year of treatment. There was no association with older age, but there was a noted association with comorbidities and treatment modality. This study focused on covariates that can affect healthcare contact. However, no raw data were provided on encounter days for all patients.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eStage IV non-small-cell lung cancer:\u003c\/strong\u003e A study of 5,785 patients from a Canadian cohort who died from stage IV non-small-cell lung cancer found a median of \u003cstrong\u003e36 contact days\u003c\/strong\u003e, which comprised \u003cstrong\u003e33% of median survival days\u003c\/strong\u003e. This study provided helpful subset analysis by systemic therapy and graphed contact days to show a \"U-shaped\" trajectory. However, the cohort had shorter survival than expected.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcute myeloid leukemia:\u003c\/strong\u003e A study of 7,946 patients with acute myeloid leukemia from SEER-Medicare found that adjusted home time was \u003cstrong\u003e52.4%\u003c\/strong\u003e. Home time was higher with hypomethylating agents than anthracyclines (\u003cstrong\u003e60.8% versus 51.9%\u003c\/strong\u003e). This study provided visually intuitive graphing of home time. The large dataset empowered covariate analysis. However, the treatment paradigm has since evolved.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAdvanced esophageal\/gastric cancer:\u003c\/strong\u003e A study of 12,378 patients from phase III randomized controlled trials found a median of \u003cstrong\u003e37 contact days\u003c\/strong\u003e (range 7 to 52 days). Contact days were significantly lower only with immunotherapy, but not for chemotherapy or chemo-immunotherapy. This study had a large sample size due to pooled analysis. However, there was indirect calculation of contact days.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eMetastatic breast cancer:\u003c\/strong\u003e A study of distinct cohorts with newly diagnosed metastatic breast cancer from a single institution and SEER-Medicare found that mean cancer-related time was \u003cstrong\u003e34.1 to 75.6 hours\u003c\/strong\u003e during a 3-month period. This was a pioneering mixed method analysis of time toxicity. However, time toxicity measurement is cumbersome and difficult to implement.\u003c\/p\u003e\n\n\u003ch2 id=\"clinical-implications\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eTime toxicity is a relevant patient-centered metric. It can be incorporated into clinical trial design and routine clinical care to influence clinical decision-making.\u003c\/p\u003e\n\n\u003cp\u003eFor patients with GU cancers, understanding time toxicity is especially important. These patients often face multiple treatment options that may offer similar survival benefits but very different time commitments. For example:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eSome treatments require indefinite duration with regular monitoring visits\u003c\/li\u003e\n  \u003cli\u003eSome treatments require travel to tertiary care centers\u003c\/li\u003e\n  \u003cli\u003eSome treatments require periods of separation from loved ones\u003c\/li\u003e\n  \u003cli\u003eSome treatments cause side effects that require additional visits and supportive care\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eBy understanding the time commitment associated with each treatment option, patients and their doctors can make more informed decisions. This is particularly important for patients with advanced cancer, whose remaining time may be limited.\u003c\/p\u003e\n\n\u003cp\u003eThe concept of time toxicity also highlights the importance of considering a patient's individual circumstances. Patients who live far from healthcare institutions may need to dedicate more time to receive the same care. Patients who work or have caregiving responsibilities may find the time commitment of certain treatments particularly burdensome.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of Current Research\u003c\/h2\u003e\n\n\u003cp\u003eThe review identified several limitations in the current research on time toxicity:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLack of GU cancer studies:\u003c\/strong\u003e Despite the rising study of time toxicity across cancer populations, there has been a surprising lack of work evaluating time toxicity in patients with GU cancers.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eVaried measurement methods:\u003c\/strong\u003e Different studies use different methods to measure time toxicity, making it difficult to compare findings across studies.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLimited granularity:\u003c\/strong\u003e Many studies do not provide detailed information on the type of contact days or the specific activities that contribute to time toxicity.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUnderpowered subgroup analyses:\u003c\/strong\u003e Some studies are underpowered for subgroup analysis, limiting the ability to identify differences between patient groups.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRecall bias:\u003c\/strong\u003e Some studies rely on patient-reported data, which may be subject to recall bias.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eEvolving treatment paradigms:\u003c\/strong\u003e Treatment standards change over time, which can limit the applicability of older study findings.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLimited generalizability:\u003c\/strong\u003e Some studies are conducted at single institutions or in specific populations, limiting the generalizability of findings.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAdditionally, the contact days method has inherent limitations. It may overestimate the time commitment for patients because not every patient encounter involves multiple hours of the day. Conversely, it may underestimate healthcare contact due to confounders such as decreased appointments due to limited access to care.\u003c\/p\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations and Future Directions\u003c\/h2\u003e\n\n\u003cp\u003eThe authors call for dedicated research on time toxicity in patients with GU cancers. They provide a dedicated section focused on scenarios and best practices to measure and collect data on time toxicity. This section can serve to spark interest in evaluating this novel health outcome in GU cancer survivors.\u003c\/p\u003e\n\n\u003cp\u003eKey recommendations include:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDevelop standardized measurement methods:\u003c\/strong\u003e A sufficiently comprehensive yet intuitive method of assessment is needed. This method should precisely quantify time estimates that can be considered in clinical decision-making.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIncorporate time toxicity into clinical trial design:\u003c\/strong\u003e Time toxicity should be measured as an outcome in clinical trials for GU cancers.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUse technology to improve measurement:\u003c\/strong\u003e The rise of tracking technology and computer-driven algorithms may refine how healthcare contact is collected and computed. Personal devices such as smartphones or watches could provide real-world evidence of time spent in different health settings.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eEngage patients in data collection:\u003c\/strong\u003e The aid of patients in capturing time toxicity outside of clinical settings will prove invaluable to derive precise measurements.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eConsider time toxicity in shared decision-making:\u003c\/strong\u003e Patients and clinicians should discuss time toxicity when considering treatment options.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStudy time toxicity across the cancer journey:\u003c\/strong\u003e Time toxicity can be studied at any point along the cancer journey, from diagnosis through survivorship.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe authors conclude that time toxicity is a relevant patient-centered metric. It can be incorporated into clinical trial design and routine clinical care to influence clinical decision-making. For patients with GU cancers, understanding time toxicity can help ensure that treatment decisions align with their values and priorities.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is time toxicity in cancer care?\u003c\/h3\u003e\n\u003cp\u003eTime toxicity is the time patients spend in contact with the healthcare system. This includes clinic visits, laboratory tests, imaging studies, time addressing complications from the disease or its treatment, and outpatient or inpatient care. This time can reduce the value of extra survival gained from treatment, especially for patients with advanced cancer whose remaining time may be limited.\u003c\/p\u003e\n\u003ch3\u003eWhy is time toxicity important for people with genitourinary cancers?\u003c\/h3\u003e\n\u003cp\u003ePeople with genitourinary cancers often have multiple treatment options that may offer similar survival benefits but very different time commitments. Some treatments require indefinite duration with regular monitoring, travel to tertiary care centers, or periods of separation from loved ones. Understanding the time commitment can help patients and doctors make more informed decisions aligned with their values and priorities.\u003c\/p\u003e\n\u003ch3\u003eHow do researchers measure time toxicity?\u003c\/h3\u003e\n\u003cp\u003eThe most widely used method separates days with and without physical healthcare contact, called contact days and home days. Any physical encounter with the health system counts as a whole day away from home. More detailed approaches combine travel time, appointment time, ancillary testing, inpatient care, and healthcare activities outside the clinic, but these are more complex to implement.\u003c\/p\u003e\n\u003ch3\u003eWhat did studies in other cancers find about time toxicity?\u003c\/h3\u003e\n\u003cp\u003eStudies in other cancers found varying results. For example, in one study of 12,378 patients with advanced esophageal or gastric cancer, median contact days were 37. In a study of 572 patients with advanced colorectal cancer, median contact days were 28 with cetuximab versus 10 with supportive care. These findings show that different treatments can have very different time commitments.\u003c\/p\u003e\n\u003ch3\u003eWhat are the limitations of current time toxicity research?\u003c\/h3\u003e\n\u003cp\u003eCurrent research has several limitations: there is a lack of studies in genitourinary cancers, different studies use different measurement methods, many studies lack detail on the type of contact days, some are underpowered for subgroup analysis, and some rely on patient-reported data subject to recall bias. Treatment standards also change over time, limiting the applicability of older findings.\u003c\/p\u003e\n\u003ch3\u003eWhat do the authors recommend for future research?\u003c\/h3\u003e\n\u003cp\u003eThe authors recommend developing standardized measurement methods, incorporating time toxicity into clinical trial design for genitourinary cancers, using technology like tracking devices to improve measurement, engaging patients in data collection, considering time toxicity in shared decision-making, and studying it across the cancer journey from diagnosis through survivorship.\u003c\/p\u003e\n\u003ch3\u003eHow can understanding time toxicity help patients make treatment decisions?\u003c\/h3\u003e\n\u003cp\u003eBy understanding the time commitment associated with each treatment option, patients and their doctors can make more informed decisions. This is especially important for patients with advanced cancer, whose remaining time may be limited. It also highlights the need to consider individual circumstances, such as distance from healthcare institutions or work and caregiving responsibilities.\u003c\/p\u003e\n\u003ch3\u003eWhen should a patient with prostate, bladder, kidney, or testicular cancer seek a second opinion about treatment time commitments?\u003c\/h3\u003e\n\u003cp\u003ePatients with genitourinary cancers often face multiple treatment options that may offer similar survival benefits but very different time commitments. Some treatments require indefinite duration with regular monitoring visits, travel to tertiary care centers, or periods of separation from loved ones; others cause side effects needing additional visits and supportive care. Because time toxicity has rarely been studied in these cancers, patients and doctors may lack clear time estimates for each option. A second opinion can help clarify how each choice fits individual circumstances, such as distance from care or work and caregiving responsibilities. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e Time's up: the urgency to investigate time toxicity in patients with genitourinary malignancies.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e Sentana-Lledo D, Morgans AK.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor affiliations:\u003c\/strong\u003e Dana-Farber Cancer Institute, Boston, MA, USA\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eJournal:\u003c\/strong\u003e Therapeutic Advances in Medical Oncology\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication details:\u003c\/strong\u003e 2024, Volume 16, pages 1-12\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDOI:\u003c\/strong\u003e 10.1177\/17588359241305088\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eArticle type:\u003c\/strong\u003e Review article\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eReceived:\u003c\/strong\u003e 29 July 2024\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eRevised manuscript accepted:\u003c\/strong\u003e 19 November 2024\u003c\/p\u003e\n\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47816804597916,"sku":null,"price":0.0,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0599\/5449\/5644\/files\/ddn-medical-article-time-spent-receiving-cancer-care-why-it-matters-for-patients-with-prostate-bladder-kidney-and-testicular-cancers-hero.png?v=1792909232","url":"https:\/\/diagnosticdetectives.com\/he\/products\/time-spent-receiving-cancer-care-why-it-matters-for-patients-with-prostate-bladder-kidney-and-testicular-cancers","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}