Physician Experience and Risk of Rituximab Discontinuation in Older Adults With Non-Hodgkin’s Lymphoma

Abstract

Background: Provider experience, or clinical volume, is associated with improved outcomes in many complex healthcare settings. Despite increased complexity of anticancer therapies, studies evaluating physician-level experience and cancer treatment outcomes are lacking. Methods: A population-based study was conducted of older adults (aged ≥66 years) diagnosed with B-cell non-Hodgkin’s lymphoma in 2004 through 2011 using SEER-Medicare data. Analysis focused on outcomes in patients receiving rituximab, the first approved monoclonal anticancer immunotherapy. We hypothesized that lower physician experience using rituximab and managing its infusion-related reactions would be associated with early treatment discontinuation. A 12-month look-back from each initiation of rituximab was used to categorize physician volume (0, 1–2, or ≥3 initiations per year). Modified Poisson regression was used to account for provider-level correlation and estimated relative risk (RR) of early rituximab discontinuation (<3 cycles within 180 days of rituximab initiation). Cox proportional hazards were used to measure the impact of rituximab discontinuation on survival. Results: Among 15,110 patients who initiated rituximab with 2,684 physicians, 7.6% experienced early rituximab discontinuation. Approximately one-fourth of patients (26.1%) initiated rituximab with a physician who had no rituximab initiations during the preceding 12 months. Compared with patients treated by physicians who had ≥3 rituximab initiations in the prior year, those treated by physicians without initiations were 57% more likely to experience early discontinuation (adjusted RR [aRR], 1.57; 95% CI, 1.35–1.82; P<.001 for 0 vs ≥3, and aRR, 1.19; 95% CI, 1.03–1.37; P=.02 for 1–2 vs ≥3). Additionally, rituximab discontinuation was associated with higher risk of death (adjusted hazard ratio, 1.39; 95% CI, 1.28–1.52; P<.001). Conclusions: Lower oncologist experience with rituximab was associated with increased risk of early rituximab discontinuation in Medicare beneficiaries with non-Hodgkin’s lymphoma. Physician-level volume may be an important factor in providing high-quality cancer care in the modern era.

Phone contacts and treatment discontinuation predict survival cancer patients in a subsidized drug access program

“…Physicians in our current study who see more patients could potentially have more experience with HL, which could impact their willingness to continue patients on therapy when AEs or complications arise. A study in patients with B-cell non-Hodgkin’s lymphoma found that lower oncologist experience with rituximab was associated with an increased risk of rituximab discontinuation [ 8 ]. Other studies have also found that physician experience with HIV/AIDS or tuberculosis had a positive effect on survival [ 28 , 29 ].…”

“…The impact of physician behavior on outcomes for patients treated with BV in low- and middle-income countries (LMICs) is not well understood. Physician experience has been shown to impact survival in patients with lymphoma and physician experience using BV in the treatment of HL may be limited in LMICs in which BV is not typically used in clinical practice [ 8 , 9 ]. Additionally, the ability for physicians and patients in these countries to manage the side effects associated with BV is also not well understood.…”