Meeting News CoveragePerspective

Many patients with terminal cancer receive aggressive end-of-life treatment

CHICAGO — Many patients aged 65 years or younger with metastatic cancer underwent aggressive treatments and invasive procedures or were admitted to the hospital as the end of life, according to an analysis of claims data presented at the ASCO Annual Meeting.

“The use of aggressive care did not decrease after ASCO's 2012 ‘Choosing Wisely’ recommendations,” Ronald C. Chen, MD, MPH, associate professor of radiation oncology and director of the cyberknife radiosurgery program at Lineberger Comprehensive Cancer of University of North Carolina in Chapel Hill, said at a press briefing. “Efforts are needed to improve end-of-life care for patients with terminal disease to ensure that care meets the goals and preferences of patients and their families.”

Aggressive medical care at the end of life — such as cancer-directed procedures and therapies, ED and ICU admissions, and in-hospital deaths — are acknowledged as harmful to patients with cancer.

The 2012 ASCO Choosing Wisely recommendations supported palliative care rather than cancer-directed treatment in patients with advanced solid tumors in patients unlikely to benefit from treatment. This included patients with a poor performance status, patients who did not benefit from prior interventions, patients ineligible for clinical trials, and patients for whom no evidence exists to support additional anticancer treatments.

Chen and colleagues evaluated the prevalence of aggressive care within the last 30 days of life among patients younger than 65 years treated before and after the Choosing Wisely recommendation.

Researchers analyzed data from HealthCore Integrated Research Database to identify 28,731 patients from 14 states in different regions of the country who died between 2007 and 2014. Patients had a diagnosis of metastatic breast (n = 5,855), colorectal (n = 5,207), lung (n = 12,764), pancreatic (n = 3,397) or prostate (n = 1,508) cancers.

In total, a range 71.2% to 75.9% of patients across all cancers analyzed received aggressive care within the final 30 days of life, and 30.3% to 35.4% of patients died in the hospital. Rates of any aggressive care use was highest of patients with lung cancer (75.9%).

The most common type of aggressive care in the last 30 days of life was hospital admission or ED visit (61.6% to 65.1% of patients). Further, 24.2% to 32.6% of patients received chemotherapy in the last 30 days of life, 25.3% to 31.1% underwent invasive procedures, 15.9% to 20.6% were admitted to the ICU, and 5.8% to 20.6% received radiation.

Only 14% to 18% of patients received hospice care.

In the 32 months following release of the Choosing Wisely recommendations, rates of aggressive care were unchanged in the colorectal and breast cohorts and higher in the lung, pancreatic and prostate cancer cohorts.

Limitations of the analysis include that researchers could not evaluate cause of death or reason for aggressive care in the 30 days preceding death.

“We are really bad at estimating a patient's life expectancy,” Chen said. “We [as oncologists] have a desire to help out patients, and we want to be able to offer them treatments as they approach end of life.” by Nick Andrews

References:

Chen R, et al. Abstract 10033. Presented at: ASCO Annual Meeting; June 3-7, 2016; Chicago.

Disclos ure: Chen reports a consultant/advisory role with Medivation/Astellas and research funding from Accuray. Please see the abstract for a complete list of relevant financial disclosures.

CHICAGO — Many patients aged 65 years or younger with metastatic cancer underwent aggressive treatments and invasive procedures or were admitted to the hospital as the end of life, according to an analysis of claims data presented at the ASCO Annual Meeting.

“The use of aggressive care did not decrease after ASCO's 2012 ‘Choosing Wisely’ recommendations,” Ronald C. Chen, MD, MPH, associate professor of radiation oncology and director of the cyberknife radiosurgery program at Lineberger Comprehensive Cancer of University of North Carolina in Chapel Hill, said at a press briefing. “Efforts are needed to improve end-of-life care for patients with terminal disease to ensure that care meets the goals and preferences of patients and their families.”

Aggressive medical care at the end of life — such as cancer-directed procedures and therapies, ED and ICU admissions, and in-hospital deaths — are acknowledged as harmful to patients with cancer.

The 2012 ASCO Choosing Wisely recommendations supported palliative care rather than cancer-directed treatment in patients with advanced solid tumors in patients unlikely to benefit from treatment. This included patients with a poor performance status, patients who did not benefit from prior interventions, patients ineligible for clinical trials, and patients for whom no evidence exists to support additional anticancer treatments.

Chen and colleagues evaluated the prevalence of aggressive care within the last 30 days of life among patients younger than 65 years treated before and after the Choosing Wisely recommendation.

Researchers analyzed data from HealthCore Integrated Research Database to identify 28,731 patients from 14 states in different regions of the country who died between 2007 and 2014. Patients had a diagnosis of metastatic breast (n = 5,855), colorectal (n = 5,207), lung (n = 12,764), pancreatic (n = 3,397) or prostate (n = 1,508) cancers.

In total, a range 71.2% to 75.9% of patients across all cancers analyzed received aggressive care within the final 30 days of life, and 30.3% to 35.4% of patients died in the hospital. Rates of any aggressive care use was highest of patients with lung cancer (75.9%).

The most common type of aggressive care in the last 30 days of life was hospital admission or ED visit (61.6% to 65.1% of patients). Further, 24.2% to 32.6% of patients received chemotherapy in the last 30 days of life, 25.3% to 31.1% underwent invasive procedures, 15.9% to 20.6% were admitted to the ICU, and 5.8% to 20.6% received radiation.

Only 14% to 18% of patients received hospice care.

In the 32 months following release of the Choosing Wisely recommendations, rates of aggressive care were unchanged in the colorectal and breast cohorts and higher in the lung, pancreatic and prostate cancer cohorts.

Limitations of the analysis include that researchers could not evaluate cause of death or reason for aggressive care in the 30 days preceding death.

“We are really bad at estimating a patient's life expectancy,” Chen said. “We [as oncologists] have a desire to help out patients, and we want to be able to offer them treatments as they approach end of life.” by Nick Andrews

References:

Chen R, et al. Abstract 10033. Presented at: ASCO Annual Meeting; June 3-7, 2016; Chicago.

Disclos ure: Chen reports a consultant/advisory role with Medivation/Astellas and research funding from Accuray. Please see the abstract for a complete list of relevant financial disclosures.

    Perspective
    Andrew S. Epstein

    Andrew S. Epstein

    The end of life for a patient with cancer is extremely difficult for the families of patients as well as for physicians. Therefore, education for providers, whether it be nurses or physicians, is extremely important to have very challenging conversation with patients and families regarding what is important to them at the end of life. Education can make these challenging conversations at least somewhat easier and allow us to marry care with what is important to people.

    • Andrew S. Epstein, MD
    • Memorial Sloan Kettering Cancer Center
    Perspective
    Lowell E. Schnipper

    Lowell E. Schnipper

    The abstract presented by Chen and colleagues at the ASCO Annual Meeting demonstrates the discouraging finding that clinical decisions made on a cancer patient’s behalf — presumably with the patient and family when life is near ending — varied little whether the decisions were made prior to or following publication of ASCO’s Choosing Wisely recommendation pertaining to this clinical circumstance. Although none would argue that caring for a dying patient poses immense psychological challenges for patient, family and physician, there is a broader observation that promotes greater concern. In a publication in JAMA Internal Medicine, Rosenberg and colleagues have shown that there was barely a change in clinical practice patterns regarding seven Choosing Wisely recommendations made by various specialty societies, despite a lack of evidence supporting the usefulness of the specific practices that were enumerated.
    Despite ample evidence that doing less actually improves quality of care — because, in effect, doing so reduces morbidity associated with false-positive tests and unnecessary expense — educational initiatives will not be sufficient to promote changes in clinical practice. Nor will honorifics suffice when bestowed on those physicians or practice groups that exemplify adherence to evidence-based recommendations. A full alignment of incentives — professional and financial — must be in place if we are to see altered behaviors in response to sensible recommendations supported by evidence. Only then might we move the needle!

    Reference:
    Rosenberg A, et al. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.5441.
    • Lowell E. Schnipper, MD, FASCO
    • HemOnc Today Editorial Board member Beth Israel Deaconess Medical Center Harvard Medical School

    Disclosures: Schnipper reports no relevant financial disclosures.

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