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25-10-2011 | Gastroenterology | Article

Hospice care underused by pancreatic cancer patients


Free abstract

MedWire News: More than a third of patients with pancreatic cancer do not use hospice care at the end of life, despite few effective therapies existing at the advanced stages of the disease and overall hospice use increasing in recent years, show study findings.

Furthermore, hospice care is not being used optimally , say the researchers, with nearly half of those who use it only doing so after receiving aggressive treatment in the last month of life.

"Hospice benefits include prolonged life, increased quality of life, and lower health costs, and physicians play a crucial role in guiding the transition from curative to palliative goals of treatment for patients with pancreatic cancer," say Kristin Sheffield (University of Texas Medical Branch, Galveston, USA) and colleagues.

"Patients referred to hospice in a late terminal stage may not receive the full benefit of hospice services," they add in the journal Cancer.

The team linked Surveillance, Epidemiology, and End Results tumor registry data (1992-2006) with Medicare claims data to assess hospice utilization and aggressive treatment among 22,818 pancreatic cancer patients at the end of life.

Patients were more often female (56.3%) and presented with distant disease (61.9%), and just over half (56.9%) used hospice before their death, with 35.9% using it at least 4 weeks before death - an indicator of early, timely enrollment.

Over the entire data period, hospice use increased by approximately 11-13% per year.

Hospice use was significantly higher in patients with unresectable locoregional disease than those with resectable locoregional or distant stage disease, report Sheffield et al. In addition, significantly more patients who visited an oncologist in the 6 months before death enrolled in hospice compared with those who did not, at 60.0% versus 51.9%.

Women, Hispanic and White individuals, unmarried patients, and those living in rural areas were the most likely to enroll into hospice early, reports the research team.

Among hospice users, early enrollment declined significantly over the study period, from 39.8% in 1992-1994 to 35.5% in 2004-2006. Conversely, write the researchers, early enrollment increased among all decedents (hospice users and nonusers), from 14.4% to 23.9%.

Two indicators of aggressive treatment, chemotherapy and admission to the intensive care unit in the last month of life, increased over the study period. The former increased from 8.1% among patients who died in 1992-1994 to 16.5% in those who died between 2004 and 2006, and the latter increased from 15.5% to 19.6% between these time periods.

Sheffield and co-workers remark that physicians' difficulty discussing death and their desire to continue curative therapy into the last stages of disease contribute to late hospice referrals, in addition to patient preference for more aggressive therapy.

They suggest that an improvement in prognostic accuracy at the end of life could improve this situation.

"Increases in the use of aggressive care at the end of life and low early enrollment in hospice suggest that hospice care is not being used optimally," the team concludes.

By Sarah Guy

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