More Medicare patients with advanced cancer are entering hospice care, but referrals continue to be very late and often just days before death, according to a new study from the Dartmouth Atlas Project of the Dartmouth Institute for Health Policy & Clinical Practice. Further, using data from 2010, the project found that despite the increase in hospice use, more patients were treated in intensive care units (ICUs) in their last month of life than in the period from 2003 to 2007. Additionally, the percentage of patients seeing 10 or more physicians in the last six months of life escalated from 46.2 percent in 2003–2007 to 58.5 percent in 2010, a situation that the report speculated may reflect fragmented care.
This is the first Dartmouth Atlas report containing a longitudinal analysis of the care provided to Medicare patients with advanced cancer. The report, “Trends in Cancer Care Near the End of Life: A Dartmouth Atlas of Health Care Brief,” examined the last six months of claims records for 212,322 Medicare patients with advanced cancer who died in 2010 and compared them with a similar data set from 2003 to 2007.
The most troubling finding from the new report is that it shows that patients with advanced care are often receiving care that does not reflect their wishes: “Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services,” said the study's lead author, David C. Goodman, MD, MS, co-principal investigator for the Dartmouth Atlas Project, in a statement accompanying the report.
The study found that in 2010 just as many patients with advanced cancer were likely to receive aggressive treatments such as endotracheal intubation, a feeding tube, or cardiopulmonary resuscitation in the last month of life or to receive chemotherapy during the last two weeks of life as in 2003–2007. “Fuller discussions with patients who have advanced cancer on their prognosis and options for care can lead to a better quality of life than many receive today,” he added.
Hudis and Byock
Commenting on the Dartmouth Atlas report in a statement, American Society of Clinical Oncology President Clifford A. Hudis, MD, said that while the increase in referrals to hospice (even if they are often late), is good news, “it's also clear there is much more we can do to improve the timely use of hospice care and avoid unnecessarily and ineffective, aggressive treatment.”
Hudis, Chief of the Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center, added, “This report should be a reminder to the oncology community: we can and must keep striving to deliver the right care at the right time.”
He noted that when patients with advanced cancer communicate with their physicians early in the course of treatment about the kind of care they want, “these important discussions lead to greater use of palliative and hospice care, and can improve a patient's quality of life, sense of control, and satisfaction with their care and choices.”
Next year, ASCO—which is on record as encouraging integration of palliative care into oncology at every stage of the cancer continuum—will host its first evidence-based Palliative Care in Oncology Symposium (asco.org/meetings/ascos-palliative-care-oncology-symposium).
Also agreeing, end-of-life care pioneer Ira Byock, MD, Professor of Medicine at the Geisel School of Medicine at Dartmouth, urged cancer patients and their physicians to make better use of the benefits of palliative care. “The longstanding assumption is that the more diagnostic tests and treatments patients receive, the better off they will be. However, two decades of studies by Dartmouth Atlas researchers have proven that this supposition is often wrong,” he said in a commentary accompanying the report.
“In advanced illnesses, including cancer, higher levels of medical treatments are commonly associated with more suffering, but little or no extension of life.”
Specifically, the Dartmouth Atlas study on advanced cancer patients found that:
* 61.3 percent of patients entered hospice care in the last month of life in 2010, compared with 54.6 percent in 2003–2007;
* 24.7 percent of patients died in the hospital in 2010, compared with 28.8 percent in 2003–2007; and
* 28.8 percent of patients were admitted to the ICU in the last month of life in 2010, compared with 23.7 percent in 2003–2007.
* The percentage of patients receiving life-sustaining in the last month of life was slightly up in 2010: 9.4 percent, compared with 9.2 percent in 2003–2007.
* The percentage of patients receiving chemotherapy in the last two weeks of life remained the same in both data sets: six percent.
The report found that the pace of improvement in use of palliative care services was “uneven and varied markedly across regions and hospitals, including academic medical centers and NCI-designated Cancer Centers.” This variation occurred even within the same state.
For example, in the Rochester, N.Y. hospital referral region, the percentage of Medicare patients with advanced cancer dying in the hospital increased from 25.4 percent in 2003–2007 to 30.5 percent in 2010. But in East Long Island, N.Y. the percentage of patients dying in the hospital decreased in 2010 to 35.6 percent from 42.5 percent in 2003–2007—even as this region continued to have one of the nation's highest in-hospital death rates for Medicare patients with advanced cancer.
Although there is an increased awareness of the importance of discussing cancer treatment choices with patients, the report found that communication gaps often undermine those discussions. For example, a recent article cited in the Dartmouth Atlas study found that the majority of patients with advanced lung and colorectal cancer did not understand that chemotherapy was unlikely to cure their cancer (Weeks et al: Patients' expectations about effects of chemotherapy for advanced cancer: NEJM 2012;367:1616–1625).
And, two years before that, an article in a 2010 theme issue of the Journal of the American Medical Association highlighted the fact that U.S. palliative care programs vary widely and differ in the extent to which they are integrated into cancer care (Hui D et al: JAMA 303;1054–1061).
In that issue, a study of palliative care services in 71 NCI-designated U.S. cancer centers and a random sample of 71 non-NCI designated cancer centers (the centers were identified by using the Commission of Cancer database) found much heterogeneity in the infrastructure and delivery of palliative care in the United States. That study found that NCI-designated cancer centers were significantly more likely to have: a palliative care program; at least one palliative care physician; an inpatient palliative care consultation team; and an outpatient palliative care clinic. However, few cancer centers had an institution-operated hospice or dedicated palliative care beds.