Palliative care reduces aggressive treatment of advanced cancer
Exposure to palliative care considerably reduced health care utilization among Medicare beneficiaries with advanced cancer, according to observational study results published in Journal of Oncology Practice.
These patients required less frequent hospitalization, underwent fewer invasive procedures and chemotherapy treatments, and appeared more likely to enroll in hospice.
“Over the past decade, we’ve had multiple clinical trials that have provided strong evidence that palliative care in oncology improves patient quality of life, decreases patient symptoms, improves caregiver well-being and may improve patient survival,” James D. Murphy, MD, MS, chief of palliative radiation therapy and gastrointestinal tumor service at University of California, San Diego, told HemOnc Today. “Despite these robust findings, clinical trial results do not always clearly translate into real-world clinical practice.”
Palliative care utilization has increased across the U.S. health care system, particularly in oncology. The proportion of hospitals with palliative care programs increased from less than 25% in 2000 to more than 67% in 2011.
Murphy and colleagues examined the effect of palliative care receipt on health care use at the end of life among 6,580 Medicare Part A and Part B beneficiaries aged older than 65 years with advanced prostate, breast, lung or colorectal cancer.
Half of those individuals received palliative care consultations and half did not.
Visits to the emergency room, hospitalization, ICU admission and hospice use during two periods — the 30 days prior to palliative care consult, and from palliative care consult until death, served as primary endpoints.
Secondary endpoints included the use of chemotherapy, initiation of new chemotherapy and use of invasive procedures, such as venous catheterization, intubation, transfusion of blood products, thoracentesis, lung or liver biopsy, or cardiopulmonary resuscitation.
Those who received palliative care had higher rates of health care utilization in the 30 days before consult than those who did not receive palliative care. This utilization included higher rates of hospitalization (RR = 3.33; 95% CI, 2.87-3.85), invasive procedures (RR = 1.75; 95% CI, 1.62-1.88) and chemotherapy administration (RR = 1.61; 95% CI, 1.45-1.78).
However, when researchers examined the period between palliative care consult until death, those in the palliative care cohort demonstrated lower rates of hospitalization (RR = 0.53; 95% CI, 0.44-0.65), invasive procedures (RR = 0.52; 95% CI, 0.45-0.59) and chemotherapy administration (RR = 0.46; 95% CI, 0.39-0.53).
After their consult, patients who received palliative care appeared 54% less likely to receive chemotherapy, 35% less likely to begin a new chemotherapy regimen and 24% more likely to enroll in hospice. They also had longer durations in hospice (25.5 days vs. 21.3 days).
Palliative care encounters occurred late in the disease course, with a median time from first consultation to death of 12 days (interquartile range, 4 to 38 days).
“Our main take-home message is that palliative care intervention can substantially reduce aggressive care at the end of life among a real-world population of patients with advanced cancer,” Murphy said. “This study supports the [previous] randomized clinical trials and emphasizes the importance of early intervention with palliative care.”
Researchers acknowledged limitations of the study, including that they did not randomly assign patients to palliative care encounters, and that those who received palliative care may have had greater disease severity than those in the control group. The data also lacked detail on the frequency, intensity and granularity of the palliative care consultations.
“Current guidelines advocate for early palliative care intervention alongside standard oncology care for patients with advanced cancer,” Murphy said. “Our study supports existing evidence, which emphasizes the importance of early integration of palliative care alongside traditional oncology care.” – by Chuck Gormley
Disclosures: The researchers report no relevant financial disclosures.