Aggressive end-of-life care for patients with terminal cancer and other illnesses is costly and not recommended.
ASCO recommends that patients with terminal cancer should receive palliative care rather than interventions that do not prolong life but do add to suffering.
According to a recent study, presented at ASCO 2016, these recommendations are going unheeded in the United States. The study showed that 75% of patients with cancer received ≥1 forms of aggressive intervention in the last 30 days of life, including chemotherapy, invasive procedures and biopsies, hospitalization, and emergency care.
The study was based on an analysis of national health claims in patients aged <65 years, making it one of the first studies of this kind to focus on a younger, non-Medicare population.
“This is one of the first and largest studies to assess end-of-life care in a non-Medicare population,” said lead investigator Ronald C. Chen, MD, MPH, of the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, who presented the findings. “Seventy to seventy-five percent of cancer patients younger than age 65 with incurable cancers received aggressive care within the last 30 days of life. One-third died in the hospital.”
The investigators also found that ASCO’s top 5 Choosing Wisely recommendations from 2012 have had little or no impact on aggressive end-of-life care for patients with cancer. There was no change in the rates for any of the interventions studied between 2012 (when the recommendations were published) through the last quarter of 2014. The recommendations stressed the value of palliative and supportive care for terminally ill patients.
“This shows that recommendations by themselves may not be enough to change practice for patients with terminal disease,” Dr Chen stated. “We need better ways of educating physicians and patients about palliative care and hospice, and we need to make these types of care more accessible.”
The study was based on claims data from the HealthCore Integrated Research Database across 14 states. The population included 28,731 patients in the United States aged <65 years who died from metastatic lung, colorectal, breast, pancreatic, or prostate cancer between 2007 and 2014. The investigators evaluated the rates of chemotherapy, radiotherapy, invasive procedures including biopsy, emergency department visits, hospitalization, intensive care, and in-hospital death within the last 30 days of life for these patients.
The rates of chemotherapy ranged from 24.2% for prostate cancer to 32.6% for breast cancer. The rates of radiotherapy ranged from 5.8% for pancreatic cancer to 20.6% for lung cancer. Invasive procedure rates ranged from 25.3% of prostate cancers to 31.1% of pancreatic cancers. Approximately 66% of all patients were admitted to the hospital or emergency department. Between 15% and 20% of patients had care in the intensive care unit. Approximately 33% died in the hospital.
Somewhat surprisingly, only 15% to 18% of these terminally ill patients accessed hospice care.
“Studies have shown that hospice can help patients preserve their quality of life at the end of life,” said Dr Chen. “We think there is too much aggressive care, and it might be related to the fact that too few of these patients enroll in hospice. It’s not clear which is the cause, but I think these are complimentary findings.”
He noted that the study raises more questions than it answers. When asked why there is little or no change in the use of aggressive care at the end of life, Dr Chen said that patient and physician factors are probably at play.
“Physicians are taught to offer some kind of treatment to help patients,” he said. “Along with that, oncologists are bad at estimating life expectancy and have difficulty with end-of-life discussions.”
By contrast, 66% of patients went to the emergency department. “These are patient-driven visits, and younger patients may want more aggressive treatment,” Dr Chen noted.
“End-of-life discussions are difficult,” agreed ASCO expert in palliative care, Andrew S. Epstein, MD, Medical Oncologist at Memorial Sloan Kettering Cancer Center, New York, NY. “Oncologists need better education to improve communication during these challenging conversations.”
“End-of-life care is highly personal for each patient, and palliative care, including hospice, remains one of our best and most underutilized resources,” he continued.
“There is no one-size-fits-all approach for end-of-life care, and there shouldn’t be. At every step of care, patients and their doctors must have thoughtful discussions about the balance of benefits to risks, including cost and side effects. Our ultimate goal as oncologists is to help patients live the longest and best lives possible, even in their last days,” Dr Epstein said.