Advanced cancer patients receive high rates of aggressive care at end of life
June 6, 2016
In the last month of their lives, younger cancer patients continued to be hospitalized and receive other aggressive treatment at high rates, found a study led by The University of North Carolina’s Lineberger Comprehensive Cancer Center.
Dr. Stacie Dusetzina
Stacie B. Dusetzina, PhD, assistant professor of health policy and management at the UNC Gillings School of Global Public Health, is a study co-author.
A national health claims analysis of cancer patients who were younger than age 65 and had metastatic disease revealed that nearly two-thirds were admitted to the hospital or visited the emergency room in the last 30 days of their lives. The researchers said nearly one-third of patients died in the hospital.
The preliminary findings (LBA 10033), presented Monday, June 6, at the annual meeting of the American Society of Clinical Oncology (ASCO), in Chicago, raises concerns for clinicians and researchers that there is substantial overuse of aggressive care for patients with incurable cancers, even after ASCO issued recommendations in 2012 encouraging physicians to reduce aggressive end-of-life care.
“Cancer treatments have side effects, and as patients get closer to the end of life, aggressive treatments also can be less effective,” said study co-author Aaron Falchook, MD, a resident in the UNC School of Medicine Department of Radiation Oncology. “In essence, we are giving patients side effects without giving them the benefits of the treatment, and that’s really the fundamental problem with aggressive care at the very end of life.”
For the study, researchers analyzed claims data from the HealthCore Integrated Research Database for 28,731 patients from around the country who were under age 65 and had metastatic lung, colorectal, breast, pancreatic or prostate cancer. They looked at how often, within the last 30 days of their lives, patients had received chemotherapy, radiation or an invasive procedure; had gone to the emergency room or were admitted to the hospital; had received intensive care; and/or had died in the hospital.
Across the five types of cancers examined, the rates of patients receiving one or more forms of aggressive care in their last 30 days of life ranged from 71 percent to 76 percent.
Looking at chemotherapy alone, the researchers found that rates ranged from 24 percent (percentage of prostate cancer patients receiving chemotherapy in their last 30 days) to 33 percent (percentage of patients with breast cancer). Rates of hospital admission or emergency room visits were some of the highest, with 62 percent of colorectal cancer patients and 65 percent of lung cancer getting hospitalized or visiting an emergency room.
“Overuse of aggressive care at the very end of life for a cancer patient can translate to increased burden on patients and their families,” Falchook said. “If these treatments are making patients sick, and if patients continue to go to the hospital, this can reduce their ability to really spend time with their loved ones at the end of life and to get the most time out of the life that they do have left.”
Falchook said some treatments, such as radiation therapy, can be beneficial to patients at the end of their lives to help ease suffering or pain. However, he said, it is important to be thoughtful about treatment delivery.
“The goal shouldn’t be that zero percent of patients receive radiation or chemotherapy — or any of these treatments — in the last 30 days of life,” Falchook said. “There is some degree of what we’d call ‘appropriate care’ at the end of life. The goal is not zero, but finding that three-fourths of patients continued to receive aggressive care was surprising.”
Ronald C. Chen, MD, MPH, a UNC Lineberger member and associate professor in the UNC School of Medicine Department of Radiation Oncology, is the study’s first author. Chen said that physicians should be having earlier discussions with their patients about palliative care, which is treatment that focuses on relieving pain or other symptoms. Palliative care focuses on maximizing a patient’s quality of life.
“Is it hard to assess when somebody has only a month to live? Maybe,” Chen said. “But palliative care discussions and hospice enrollment should happen much earlier than a patient’s last month of life.”
Researchers also found that rates of aggressive care did not decline after the release of ASCO’s 2012 “Top Five” recommendations in 2012. The recommendations advised against using treatments to stop, slow or eliminate cancer for patients with solid tumors for whom there is not strong evidence for the treatment’s clinical value. Instead, ASCO recommended using palliative or supportive care. The recommendations were issued as part of the Board of Internal Medicine’s “Choosing Wisely” campaign.
“This study shows that recommendations alone may not be enough to change practice,” Chen said. “Along with published recommendations, more interventions targeted toward physician and patient education may be necessary to get actual changes in practice.”
Related to their finding of high rates of aggressive care at the end of life, the investigators also found that only 15 to 19 percent of patients received hospice services.
“Studies have shown that hospice can help patients preserve their quality of life at the end of life,” Chen said. “We think there’s too much aggressive care, and it might relate to the fact that too few of these patients are enrolled in hospice. It’s not clear which phenomenon is causing the other, but I think these are complementary findings.”
Chen said there were limitations of the study, including the fact that the researchers could not determine the intent of the treatment delivered in their study of aggressive care. More research is needed to identify drivers of the use of aggressive care.
In addition to Chen, Falchook and Dusetzina, co-authors include F. Tian; R. Basak, research associate in radiation oncology; L.C. Hanson, professor of med-geriatric medicine in the UNC School of Medicine, co-director of UNC’s palliative care program, UNC Lineberger member and adjunct professor of epidemiology in UNC’s Gillings School; and N. Selvam. Dusetzina also is an associate member of UNC Lineberger and assistant professor of pharmaceutical outcomes and policy at the UNC Eshelman School of Pharmacy.
The study was funded by the North Carolina Translational and Clinical Sciences Institute and the UNC School of Medicine Department of Radiation Oncology.
This news originally was published by UNC Lineberger Comprehensive Cancer Center.
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Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or dpesci@unc.edu
