Aggressive End-of-Life Care Still Offered to Younger, Non-Medicare Patients with Cancer

Aggressive end-of-life care for patients with terminal cancer and other illnesses is costly and not recommended. The American Society of Clinical Oncology (ASCO) recommends that patients with terminal cancer should receive palliative care rather than interventions that do not prolong life but do add to suffering.

However, these recommendations are going unheeded in the United States. According to a study presented at the 2016 ASCO annual meeting, 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, and is one of the first 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. 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,” said lead investigator Ronald C. Chen, MD, MPH, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, who presented the study findings.

Underuse of Hospice Care

The investigators also found that ASCO’s top 5 “Choosing Wisely” recommendations have had little or no impact on aggressive end-of-life care for patients with cancer; however, there was no change in the rates of any of the aggressive interventions between 2012 and the end of 2014. The recommendations were published in 2012 and 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. 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,” emphasized Dr Chen.

Based on claims data from the HealthCore Integrated Research Database across 14 states, the study included 28,731 patients aged <65 years who died from metastatic lung, colorectal, breast, pancreatic, or prostate cancer between 2007 and 2014 in the United States.

The investigators evaluated the rates of chemotherapy, radiotherapy, invasive procedures (eg, biopsy), emergency department visits, hospitalizations, use of intensive care, and in-hospital deaths within the last 30 days of life. The rates of chemotherapy ranged from 24.2% for prostate cancer to 32.6% for breast cancer; radiotherapy ranged from 5.8% for pancreatic cancer to 20.6% for lung cancer; and invasive procedures ranged from 25.3% for prostate cancer to 31.1% for pancreatic cancer.

Approximately 66% of patients were admitted to the hospital or the emergency department. “These are patient-driven visits, and younger patients may want more aggressive treatment,” Dr Chen noted. In addition, between 15% and 20% of patients received care in the intensive care unit, and approximately 33% of patients died in the hospital.

One surprising finding was that 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. 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 complementary findings,” said Dr Chen.

End-of-Life Education Needed

Dr Chen noted that this 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, he said that patient and physician factors may be at play.

“Physicians are taught to offer some kind of treatment to help patients. Along with that, oncologists are bad at estimating life expectancy, and have difficulty with end-of-life discussions,” he said.

“End-of-life discussions are difficult. Oncologists need better education to improve communication during these challenging conversations,” agreed ASCO expert in palliative care Andrew S. Epstein, MD, Medical Oncologist at Memorial Sloan Kettering Cancer Center, New York, NY.

“End-of-life care is highly personal for each patient, and palliative care, including hospice, remains one of our best and most underutilized resources,” Dr Epstein added.

“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.

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