August 06, 2015
5 min read
Save

End-of-life care may be too intense among AYA patients with advanced cancer

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

More than two-thirds of adolescent and young adult patients with advanced cancer receive at least one form of medically intensive care at the end of life, according to study results.

“That includes interventions like chemotherapy within the last 2 weeks of life, more than one emergency room visit in the last month of life, intensive care unit care in the last month of life, and hospitalization in the last month of life,” researcher Jennifer W. Mack, MD, MPH, co-director of the pediatric hematology/oncology fellowship program and senior physician at Dana-Farber Cancer Institute and assistant professor in pediatrics at Harvard Medical School, told HemOnc Today.

Jennifer W. Mack, MD, MPH

Jennifer W. Mack

Although adult patients who know they are dying usually do not want aggressive care, limited data exist with regard to adolescents and young adults (AYA).

Mack and colleagues sought to evaluate the rate of end-of-life care measures in AYA patients who died of cancer and received care within the Kaiser Permanente Southern California health system between 2001 and 2010. The study comprised 663 patients aged 15 to 39 years.

The investigators assessed end-of-life chemotherapy, hospitalizations, ED visits and ICU care.

Overall, 68% of the patients received at least one form of medically intensive end of life care.

The researchers found that 11% of patients received chemotherapy within the final 14 days of life. In the final month of life, 22% of patients received care in the ICU, 22% had more than one visit to the ED and 62% were hospitalized.

Patients who were hospitalized in the last month of life were more likely to receive chemotherapy during the last 14 days of life (OR = 2.29; 95% CI, 1.29-4.1). They also were more likely to undergo ICU care (OR = 5.66; 95% CI, 3.35-9.55) and have more than one ED visit (OR = 13.44; 95% CI, 6.70-26.96) in the last month of life.

However, researchers determined no association between ED visits and either chemotherapy use (OR=1.19; 95% CI, 0.68-2.11) or ICU care (OR = 1.35; 95% CI, 0.88-2.07).

“Rates of intensive measures among adolescent and young adult patients exceed proposed desirable benchmarks among older adults,” Mack and colleagues wrote. “In addition, rates for emergency department and ICU utilization among adolescent and young adult patients exceed those of Medicare decedents with advanced cancer in the last month of life.”

It remains unclear how these end-of-life decisions were unfolding for these patients, Mack told HemOnc Today.

“Older patients who know they are dying often do not want to receive aggressive care, which is associated with poorer quality of life near death,” Mack said. “However, we do not know if young people feel the same way. Some may want to receive aggressive measures in hopes of living as long as possible. More research is needed to understand what is important to young people at the end of life.

“In addition, physicians who care for adolescent and young adult cancer patients should ensure that young people understand what is ahead, especially if cure is not possible, and open conversations about what is most important to young patients as they approach the end of their lives,” Mack said. “In doing so, we can ensure that care supports their wishes.”

A study like this could be the impetus for an investigation into end-of-life decision-making in this younger patient population, Archie Bleyer, MD, FRCP, clinical research professor at Oregon Health and Science University, wrote in an accompanying editorial.

“[This study] provides a needed stimulus to investigation, and peer-reviewed publication of studies, of end of life in adolescent and young adult patients with cancer,” Bleyer wrote. “As described by Weiner et al, health care workers are in particular need of training in palliative care of adolescent and young adult patients with cancer. Epidemiologic, developmental and psychosocial factors make the provision of palliative care especially challenging in adolescents and young adults. Critical instructional strategies include experiential learning, group didactic opportunities, shared learning among care disciplines, use of bereaved family members as educators and online learning.” – by Anthony SanFilippo

References:

Mack JW, et al. JAMA Oncol. 2015;doi:10.1001/jamaoncol.2015.1953.

Bleyer A. JAMA Oncol. 2015;doi:10.1001/jamaoncol.2015.2038.

Weiner L, et al. Clin Oncol Adolesc Young Adults. 2015;5:1-18.

For more information:

Jennifer W. Mack, MD, MPH, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: jennifer_mack@dfci.harvard.edu

Disclosure: The researchers report no relevant financial disclosures. Bleyer reports a consultant and speakers bureau roles with Sigma-Tau Pharmaceuticals.