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Aggressive end-of-life care is often harmful to patients and their families, yet is still so widely used.
An analysis of over 28,000 patients younger than 65 with incurable cancers found that approximately three-fourths received aggressive care within their last 30 days of life and one-third died in the hospital, according to findings presented at the 2016 Annual Meeting of the American Society of Clinical Oncology (ASCO), a gathering of 30,000 oncology professionals in Chicago.
The analysis, which included patients with five different types of metastatic cancer, also found that the provision of aggressive care at the end of life was not impacted by ASCO’s Choosing Wisely recommendations, issued in 2012 to help balance costs against actual value, which strongly advised against cancer-directed therapy in patients with advanced solid tumors who are unlikely to benefit from it. The recommendation instead encouraged a focus on symptom-directed palliative care, but this analysis found no increase in hospice care use since 2012.
“Aggressive medical care for patients with incurable cancers at the end of life is widely recognized to be harmful to patients and their families,” said Ronald C. Chen, an oncologist at UNC Lineberger Comprehensive Cancer Center, who presented the analysis at an ASCO press conference. “Additional efforts are critically needed to improve end-of-life care for patients with terminal disease to ensure that the care provided meets the goals and preferences of patients and their families.”
The study looked at data from large commercial insurance claims of patients in 14 states. Patients were less than 65 years of age, had metastatic cancer of the lung, breast, prostate, colon or pancreas, and died between 2007 and 2014. The study examined six indicators of aggressive care at the end of life: chemotherapy, radiation, invasive procedures (eg, biopsy, surgery), emergency department visits/hospitalization, intensive care and in-hospital death.
The study included patients with the following types of cancer: lung (12,764), breast (5855), colorectal (5207), pancreatic (3397) and prostate (1508).
Incidence of each aggressive therapy was remarkably similar across all five cancer types, said Chen.
The most common form of aggressive care was hospital admission or emergency department visit, occurring in 65 percent of patients with lung or pancreatic cancer, 62 percent of patients with colorectal or prostate cancer and 64 percent of patients with breast cancer.
Notably, fewer than that one in five patients in the study utilized hospice care, said Chen.
Across all five cancers investigated, during the last 30 days of life, the chemotherapy rate ranged from approximately 24 percent to 33 percent of patients, the invasive procedure rate from 25 percent to 31 percent, and ICU care from 16 percent to 21 percent.
Radiotherapy was the least utilized treatment at the end of life, and also the most inconsistently prescribed across cancer types. Rates of use ranged from approximately 6 percent in pancreatic cancer to 21 percent in lung cancer.
In addition, the study found that between 30 percent and 35 percent of patients across all five of the tumor types investigated died in the hospital.
The overall rate of any aggressive care was 75 percent for lung and pancreatic cancer, 74 percent for breast cancer, 72 percent for prostate cancer and 71 percent for colorectal.
Study investigators also analyzed treatment trends before 2012 and between the first quarter of 2012 and the fourth quarter of 2014.
“The percentage of patients who received aggressive care over the last 30 days of life really didn’t change over time in these five cancers, said Chen. “We also saw little change before 2012, and the use of aggressive care did not seem to decrease after ASCO’s 2012 Choosing Wisely recommendations.”
While it is unclear exactly why the ASCO recommendations did not result in any changes, the bigger issue is why there are not more initiatives to improve end-of-life care overall, said press panel moderator Patricia Ganz, an ASCO expert in breast cancer.
“While Dr. Chen focused on Choosing Wisely in 2012, giving chemotherapy in the last 30 days of life has been a coping measure for a very long time, and it has been nationally looked at as one of our failures in giving good end-of-life care,” said Ganz.
“The fact that there wasn’t any dramatic change in 2012 doesn’t really bother me in the sense that we’ve been talking about this for a very long time and we haven’t seen any movement. We have a lot yet to do in terms of delivering high-quality end-of-life care.”
It is most likely that end-of-life aggressive treatment is driven both by patients and their doctors, said Chen.
Oncologists are not always aware or accepting that a patient is nearing the end of life, and they may be motivated to continue to treat the patient by a strong desire to help them, despite survival chances, said Chen. However, the study also showed that two-thirds of patients went to the emergency department or were admitted to the hospital at the ends of their lives, suggesting that patients may also play an active role in the high rate of aggressive treatment at that stage.
“These younger patients may want to continue to receive aggressive care for their cancers,” said Chen.
While it is ultimately up to a patient whether he or she would like to continue receiving aggressive treatment at the end of life, oncologists and oncology nurses need to do a better job of discussing patients’ wishes and educating them on their options, said Andrew Epstein, a press briefing panelist and an ASCO expert in palliative care. “Education for any clinician, whether it is a physician, a nurse or others, is extremely important in order to improve their ability to have these very challenging conversations about the end of life and what is important to patients and their families,” said Epstein. “We need to teach oncology professionals, especially doctors, in order to make these very, very challenging conversations easier. We need to find out what is important to patients and their families and marry the care delivered to what they say is important.”
Next steps for this research could include using this dataset to compare end-of-life aggressive treatment rates in younger patients to those in older patients, said Ganz. Previous studies have shown that elderly patients have similar rates of aggressive treatment in their last 30 days of life, but no side-by-side comparison has been done, she said.
“Looking at the younger patients, we need to know if they are being treated more aggressively than the older population, what the patterns of care are and if they mimic what is seen in the older population,” said Ganz. “This is a really great opportunity from this database to begin to look at this.”