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Palliative care reduces aggressive treatment of advanced cancer
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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.
Perspective
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This is an impressive study conducted in a large cohort of patients with cancer from the respected SEER database. The researchers adopted a careful and thoughtful approach to study design and data analysis, and they paid appropriate attention to potentially confounding variables, such as the importance of comorbidities. Careful techniques to ensure appropriate matching still resulted in a study population of nearly 8,000 patients.
Importantly, these were common high-impact diseases that represent the core of international medical oncology practice. Further, because of the complexity of these illnesses when metastatic, the population studied encapsulates the challenges inherent in the complex psychological and physical challenges of advanced metastatic disease. The study used appropriate primary and secondary outcome measurements that were concrete, well defined, and important for the administration of cancer care and the wider health care system.
It must be noted that the population consisted only of those with solid tumors from within a Medicare population. In addition, the study had a retrospective observational design. It is also noteworthy that only a small percentage of the SEER population actually received a palliative care consult. Nevertheless, the matched populations were well balanced on multiple important criteria.
The results are striking — particularly as the consults were typically late in the disease course, leaving less time to demonstrate an effect. The researchers specifically addressed the issue of the timing of consults, and the results from both primary and secondary outcome measures emphatically supported earlier introduction of palliative medicine into the plan of care. The results also are internally consistent in that all of the outcomes of interest moved in the same positive direction, increasing the credibility and generalizability of the findings.
The observation that those consulted for palliative care had greater health care utilization than controls — before the actual palliative care consultation — is somewhat puzzling and raises the issue of whether some other dynamic was at work. Nevertheless, this does not detract from the overall results and conclusions.
This is an important addition to the prior literature on this topic. It supports findings that the addition of palliative medicine to traditional cancer services is better for patients with cancer. This is now supported by multiple outcomes — both clinical and economic — and is best done earlier in the disease trajectory as a standard of care.
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