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Jeong W, Kim S, Kim H, Park EC, Jang SI. Effects of life-sustaining treatment plans on healthcare expenditure and healthcare utilization. BMC Health Serv Res 2023; 23:1236. [PMID: 37950202 PMCID: PMC10638738 DOI: 10.1186/s12913-023-10235-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE To develop an ethical and cultural infrastructure for Life-Sustaining Treatment (LST) plan, it is crucial to carefully analyze its impact and ensure that healthcare utilization is maintained at an appropriate level, avoiding excessive medical interventions. This study aims to investigate the effects of LST decisions on both healthcare expenditure and utilization. METHODS This cohort study utilized claims data from the National Health Insurance Service, encompassing all medical claims in South Korea. We included individuals who had planned to withdraw or withhold their LST between January and December 2018, identified by claim code IA71, IA72, IA73. We followed a total of 28,295 participants with documented LST plan who were deceased by June 2020. Participants were categorized into LST withdrawal / withholding and LST continuation groups. The dependent variables were healthcare expenditure and utilization. We construct a generalized linear model to analyze the association between these variables. RESULTS Out of the 28,295 participants, 24,436 (86.4%) chose to withdraw or withhold LST, while the rest opted for its continuation. Compared to the LST continuation group, those who chose to withdraw or withhold LST had 0.91 times lower odds for total cost. Additionally, they experienced 0.91 times fewer hospitalization days and 0.92 times fewer outpatient visits than those in the LST continuation group. CONCLUSION Healthcare expenditure and utilization deceased among those choosing to withdraw or withhold LST compared to those continuing it. These findings underscore the significance of patients actively participating in decision regarding their treatment to ensure appropriate levels of medical intervention for LST. Furthermore, they emphasize the critical role of proper education and the establishment of a cultural framework for LST plans.
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Affiliation(s)
- Wonjeong Jeong
- Cancer Knowledge & Information Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Selin Kim
- Review and Assessment Research Department, Health Insurance Review & Assessment Service, Wonju, Republic of Korea
| | - Hyunkyu Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine & Institute of Health Services Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sung-In Jang
- Department of Preventive Medicine & Institute of Health Services Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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2
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Tal O, Ben Shem E, Peled O, Elyashiv O, Levy T. Age Disparities in End of Life Symptom Management Among Patients with Epithelial Ovarian Cancer. J Palliat Care 2023; 38:184-191. [PMID: 35225068 DOI: 10.1177/08258597221083418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the symptoms of women with epithelial ovarian cancer (EOC) during their last admission before death and analyze invasive palliative management administered in relation to symptom control and survival. MATERIALS & METHODS A retrospective review of Israeli patients with EOC, primary peritoneal cancer (PPC) and tubal cancer, admitted to our department prior to death between 2008-2018. Basic palliative treatment was defined as administration of IV fluids, analgesics, oxygen, antiemetics, antibiotics and/or blood transfusions. Procedures regarded as invasive included: peritoneal or pleural fluid drainage; placement of an indwelling catheter, administration of total parenteral nutrition (TPN), chemotherapy and ventilation. RESULTS 82 patients were included. Most suffered from weakness and fatigue, gastrointestinal complaints, pain and shortness of breath. 34 patients (41.5%) required only basic palliative treatment to alleviate their symptoms; however, in 48 patients (58.5%) invasive interventions were needed. Patients treated with invasive procedures were younger at death by almost 9 years (mean age of 65.73 ± 9.5 vs. 74.78 ± 9.8; p = 0.001). There were significantly more women with platinum sensitive disease in the invasive interventions group compared to the basic palliative care (60.42% vs. 32.35%; p = 0.012). No survival difference was found between the groups from diagnosis to death, relapse to death, last chemotherapy to death and last admission to death. CONCLUSIONS EOC patients suffer from high disease burden and multiple symptoms before death. We found that physicians tend to use more invasive care in dying younger patients. However, this aggressive treatment does not prolong survival. Futile treatments influencing quality of life should be avoided.
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Affiliation(s)
- Ori Tal
- E. Wolfson Medical Center, Holon, Sackler Medicine, Tel Aviv University, Holon, Israel
| | - Erez Ben Shem
- E. Wolfson Medical Center, Holon, Sackler Medicine, Tel Aviv University, Holon, Israel
| | - Ofri Peled
- E. Wolfson Medical Center, Holon, Sackler Medicine, Tel Aviv University, Holon, Israel
| | - Osnat Elyashiv
- E. Wolfson Medical Center, Holon, Sackler Medicine, Tel Aviv University, Holon, Israel
| | - Tally Levy
- E. Wolfson Medical Center, Holon, Sackler Medicine, Tel Aviv University, Holon, Israel
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Campbell R, King MT, Stockler MR, Lee YC, Roncolato FT, Friedlander ML. Patient-Reported Outcomes in Ovarian Cancer: Facilitating and Enhancing the Reporting of Symptoms, Adverse Events, and Subjective Benefit of Treatment in Clinical Trials and Clinical Practice. Patient Relat Outcome Meas 2023; 14:111-126. [PMID: 37188148 PMCID: PMC10178904 DOI: 10.2147/prom.s297301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/25/2023] [Indexed: 05/17/2023] Open
Abstract
Patient-reported outcomes (PROs) provide a valid, standardized way of assessing symptoms, adverse events and the subjective benefit of treatment from the patient's perspective. Assessment of PROs is critical in ovarian cancer due to the high morbidity of the disease and its treatments. Several well-validated PRO measures are available to assess PROs in ovarian cancer. Their inclusion in clinical trials can provide evidence on the benefits and harms of new treatments based on patients' experiences to guide improvements in clinical practice and health policy. Aggregate PRO data collected in clinical trials can be used to inform patients about likely treatment impacts and assist them to make informed treatment decisions. In clinical practice, PRO assessments can facilitate monitoring of a patient's symptoms throughout treatment and follow-up to guide their clinical management; in this context, an individual patient's responses can facilitate communication with their treating clinician about troublesome symptoms and their impact on their quality of life. This literature review aimed to provide clinicians and researchers with a better understanding of why and how PROs can be incorporated into ovarian cancer clinical trials and routine clinical practice. We discuss the importance of assessing PROs throughout the ovarian cancer disease and treatment trajectory in both clinical trials and clinical practice, and provide examples from existing literature to illustrate the uses of PROs as the goals of treatment change in each setting.
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Affiliation(s)
- Rachel Campbell
- University of Sydney, Faculty of Science, School of Psychology, Sydney, NSW, Australia
- Correspondence: Rachel Campbell, University of Sydney, Room 325, Brennan-Maccallum Building, Sydney, NSW, 2006, Australia, Tel +61 2 8627 7631, Email
| | - Madeleine T King
- University of Sydney, Faculty of Science, School of Psychology, Sydney, NSW, Australia
| | - Martin R Stockler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Yeh Chen Lee
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Medical Oncology, Prince of Wales and Royal Hospital for Women, Sydney, NSW, Australia
| | - Felicia T Roncolato
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
- MacArthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, NSW, Australia
| | - Michael L Friedlander
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Medical Oncology, Prince of Wales and Royal Hospital for Women, Sydney, NSW, Australia
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4
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Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction. Gynecol Oncol 2022; 167:523-531. [PMID: 36344293 DOI: 10.1016/j.ygyno.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making. METHODS Four strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained. RESULTS In the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329-$50,162) and provided the highest QALYs (0.089; 0.089-0.090). The lowest cost strategy was hospice ($14,591; $14,527-$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%. CONCLUSIONS TPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.
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Zanolli NC, Gatta LA, Fish L, Falkovic M, Lorenzo A, Puechl AM, Havrilesky LJ, Davidson B. A Qualitative Assessment of Patient Experience following Systematic Implementation of Goals of Care Conversations in the Ambulatory Gynecologic Oncology Setting. Palliat Med Rep 2022; 3:308-315. [DOI: 10.1089/pmr.2022.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nicole C. Zanolli
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Luke A. Gatta
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura Fish
- Duke Cancer Institute Behavioral Health and Survey Research Core, Durham, North Carolina, USA
| | - Margaret Falkovic
- Department of Population Health Sciences, Durham, North Carolina, USA
| | - Amelia Lorenzo
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Allison M. Puechl
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Brittany Davidson
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina, USA
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Mullins MA, Uppal S, Ruterbusch JJ, Cote ML, Clarke P, Wallner LP. Physician Influence on Variation in Receipt of Aggressive End-of-Life Care Among Women Dying of Ovarian Cancer. JCO Oncol Pract 2022; 18:e293-e303. [PMID: 34582262 PMCID: PMC8932499 DOI: 10.1200/op.21.00351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 09/01/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE End-of-life care for women with ovarian cancer is persistently aggressive, but factors associated with overuse are not well understood. We evaluated physician-level variation in receipt of aggressive end-of-life care and examined physician-level factors contributing to this variation in the SEER-Medicare data set. METHODS Medicare beneficiaries with ovarian cancer who died between 2000 and 2016 were included if they were diagnosed after age 66 years, had complete Medicare coverage between diagnosis and death, and had outpatient physician evaluation and management for their ovarian cancer. Using multilevel logistic regression, we examined physician variation in no hospice enrollment, late hospice enrollment (≤ 3 days), > 1 emergency department visit, an intensive care unit stay, terminal hospitalization, > 1 hospitalization, receiving a life-extending or invasive procedure, and chemotherapy (in the last 2 weeks). RESULTS In this sample of 6,288 women, 51% of women received at least one form of aggressive end-of-life care. Most common were no hospice enrollment (28.9%), an intensive care unit stay (18.6%), and receipt of an invasive procedure (20.7%). For not enrolling in hospice, 9.9% of variation was accounted for by physician clustering (P < .01). Chemotherapy had the highest physician variation (12.4%), with no meaningful portion of the variation explained by physician specialty, volume, region, or patient characteristics. CONCLUSION In this study, a meaningful amount of variation in aggressive end-of-life care among women dying of ovarian cancer was at the physician level, suggesting that efforts to improve the quality of this care should include interventions aimed at physician practices and decision making in end-of-life care.
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Affiliation(s)
- Megan A. Mullins
- Center for Improving Patient and Population Health and Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Shitanshu Uppal
- Department of Gynecologic Oncology, University of Michigan, Ann Arbor, MI
| | - Julie J. Ruterbusch
- Wayne State University School of Medicine and Karmanos Cancer Institute, Detroit, MI
| | - Michele L. Cote
- Wayne State University School of Medicine and Karmanos Cancer Institute, Detroit, MI
| | - Philippa Clarke
- Department of Epidemiology and Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Lauren P. Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Paulsen T, Liland H, Myklebust TÅ, Lindemann K. Early referral to a palliative team improves end-of-life care among gynecological cancer patients: a retrospective, population-based study. Int J Gynecol Cancer 2022; 32:181-188. [PMID: 34987096 DOI: 10.1136/ijgc-2021-002898] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess end-of-life care among patients with gynecological cancer, and to describe the association between timing of palliative care referral and patterns of care. METHODS All women with residence in Oslo, Norway, who died of gynecological cancer between January 1, 2015 and December 30, 2017 (36 months), were identified. Patients were primarily treated at the Norwegian Radium Hospital and clinical data on end-of-life care were retrospectively extracted from the medical records. RESULTS We identified 163 patients with median age 70.1 years at death (range 26-100) with the following diagnoses: ovarian (n=100), uterine (n=40), cervical (n=21), and vulvar cancer (n=2). 53 (33%) of patients died in a palliative care unit, 34 patients (21%) died in nursing homes without palliative care, and 48 (29%) patients died in hospital. Only 15 (9%) patients died at home. 25 (15%) patients received chemotherapy in the last 30 days before death, especially ovarian cancer patients (n=21, 21%). 103 patients (61%) were referred to a palliative team prior to death. Referral to a palliative team was associated with a significantly reduced risk of intensive care unit admission (OR 0.11, 95% CI 0.02 to 0.62) and higher likelihood of a structured end-of-life discussion (OR 2.91, 95% CI 1.03 to 8.25). Palliative care referral also seemed to be associated with other quality indicators of end-of-life care (less chemotherapy use, more home deaths). CONCLUSIONS End-of-life care in patients with gynecological cancer suffers from underuse of palliative care. Chemotherapy is still commonly used towards end-of-life. Early palliative care referral in the disease trajectory may be an important step towards improved end-of-life care.
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Affiliation(s)
- Torbjørn Paulsen
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway .,Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Heidi Liland
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Registration, Cancer Registry of Norway, Oslo, Norway.,Department of Research and Innovation, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Kristina Lindemann
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Watson CH, Puechl AM, Lim S, Monuszko K, Truong T, Havrilesky LJ, Davidson BA. Chemotherapy discontinuation processes in a gynecologic oncology population. Gynecol Oncol 2021; 161:508-511. [PMID: 33771398 DOI: 10.1016/j.ygyno.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We sought to categorize the processes by which gynecologic oncology patients stop chemotherapy and to evaluate associations between these processes and end-of-life outcome metrics. METHODS A cohort of patients with metastatic or recurrent gynecologic cancer in an outpatient setting from January 2016 to May 2018 was identified. All deceased patients in this cohort were included for analysis. Processes of discontinuing chemotherapy were categorized as: 1) definitive decision inpatient; 2) definitive decision outpatient; 3) delayed decision (eg: treatment break and never resumed chemotherapy); 4) no decision. Associations between patient characteristics and clinical outcomes of those who made a definitive outpatient decision versus those who made any other type of decision were assessed. RESULTS 220 patients were identified; 205 patients were deceased at time of analysis. Of these, 36.6% made a definitive decision to stop chemotherapy as an outpatient, while 41.5% never made a decision to discontinue chemotherapy. Making a definitive decision as an outpatient, when compared to all other decision types, was associated with significantly lower incidence of death in the hospital (5.6% vs 21.1%, p < 0.004) and hospitalization within 30 days of death (20.8% vs 56.6%, p < 0.001), and significantly increased median time from last chemotherapy to death (135.5 vs 62 days, p < 0.001). CONCLUSION Only one in three women in this cohort of patients deceased from gynecologic cancer made a definitive decision to discontinue chemotherapy in an outpatient setting, and this process was associated with improved end-of-life outcomes. Future efforts should examine the impact of interventions designed to increase the proportion of patients who transition away from chemotherapy via shared decision making in the outpatient setting.
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Affiliation(s)
- Catherine H Watson
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States.
| | - Allison M Puechl
- Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - Stephanie Lim
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States
| | - Karen Monuszko
- Duke University, School of Medicine, Durham, NC, United States
| | - Tracy Truong
- Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, United States
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
| | - Brittany A Davidson
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
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Joung SY, Lee CW, Choi YS, Kim SM, Park SW, Mo ES, Park JH, Shin J, Lee HJ, Park HS. Analysis of the Time Interval between the Physician Order for Life-Sustaining Treatment Completion and Death. Korean J Fam Med 2020; 41:392-397. [PMID: 32429012 PMCID: PMC7700825 DOI: 10.4082/kjfm.19.0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/11/2019] [Accepted: 10/04/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND This study aimed to explore the time interval distribution pattern between the Physicians Order for Life-Sustaining Treatment (POLST) form completion and death at a tertiary hospital in South Korea. It also examined the association between various independent parameters and POLST form completion timing. METHODS A total of 150 critically ill patients admitted to Korea University Guro Hospital between June 1, 2018 and December 31, 2018 who completed the POLST form were retrospectively analyzed and included in this study. Data were analyzed with descriptive statistics, and group comparisons were performed using the chi-square test for categorical variables. Fisher's exact test was also used to compare cancer versus non-cancer groups. RESULTS More than half the decedents (54.7%) completed their POLST within 15 days of death and 73.4% within 30 days. The non-cancer group had the highest percentage of patients (77.8%) who died within 15 days of POLST form completion while the colorectal (39.1%) and other cancer (37.5%) groups had the lowest (P=0.336). CONCLUSION Our findings demonstrated a current need for more explicit guidance to assist physicians with initiating more timely, proactive end-of-life discussions.
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Affiliation(s)
- Sung Yoon Joung
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Chung-woo Lee
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Seon Mee Kim
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Seok Won Park
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Eun Shik Mo
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jae Hyun Park
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jean Shin
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Hyun Jin Lee
- Department of Family Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seok Park
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
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Pyeon SY, Han GH, Ki KD, Lee KB, Lee JM. Effect of delayed palliative chemotherapy on survival of patients with recurrent ovarian cancer. PLoS One 2020; 15:e0236244. [PMID: 32701994 PMCID: PMC7377458 DOI: 10.1371/journal.pone.0236244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023] Open
Abstract
For patients with recurrent ovarian cancer, the goals of chemotherapy include palliation of disease-related symptoms with minimum treatment-related side effects. However, there is currently a paucity of data regarding the initiation of palliative chemotherapy. This study aimed to compare the differences in survival rates and toxicities between patients with recurrent ovarian cancer who started palliative chemotherapy immediately versus those who received delayed chemotherapy. Through a retrospective chart review, patients who received more than three lines of chemotherapy were included. Based on the timing of third-line chemotherapy initiation, the patients were divided into two groups: delayed (DTG) and immediate (ITG) treatment groups. The chi-square test or Fisher’s exact tests, and t-test or Mann-Whitney U test were used for comparing variables, as appropriate. The Kaplan-Meier method was used for survival analysis. P-value of <0.05 was considered significant. Although there was no statistically significant difference, the total number of regimens and cycles was lower in the DTG than in the ITG. No differences in toxicities and survival rates were observed between the two groups. Overall, survival and toxicity did not differ significantly between the two groups. In a palliative care setting, our findings suggest that delaying the treatment had no adverse effect on survival. Despite the lack of evidence of a survival benefit with aggressive treatment, patients chose to continue chemotherapy. Because recurrent ovarian cancer is a complex condition, patients require sufficient explanation and time to fully understand the costs and benefits related to aggressive chemotherapy.
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Affiliation(s)
- Seung Yeon Pyeon
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Gwan Hee Han
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Kyung Do Ki
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Kwang-Beom Lee
- Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Gachon University College of Medicine, Inchon, Republic of Korea
| | - Jong-Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
- * E-mail:
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11
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Lindemann K, Martinsson L, Kaasa S, Lindquist D. Elderly gynaecological cancer patients at risk for poor end of life care: a population-based study from the Swedish Register of Palliative Care. Acta Oncol 2020; 59:636-643. [PMID: 32238040 DOI: 10.1080/0284186x.2020.1744717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Introduction: Poorer end-of-life (EOL) care for elderly cancer patients has been reported. We assessed the impact of age on 13 indicators for the quality of EOL care as well as adherence to 6 national quality indicators in gynaecological cancer patients.Methods: Age-dependent differences in 13 palliative care quality indicators were studied in gynaecological cancer patients registered in the population-based Swedish Register of Palliative Care. Association between the patient's age and each quality indicator was analyzed by logistic regression, adjusted for place of death where appropriate. Adherence to six national quality indicators determined by the Swedish National Board of Health and Welfare was estimated in all patients.Results: We included 3940 patients with the following age distribution: 1.6% were 18-39 years of age, 12.3% 40-59 years, 37.2% 60-74 years, 28.9% 75-84 years and 20% were ≥85 years. Age-dependent differences in implementation rate were present for some of the 13 quality indicators. Compared to elderly cancer patients, younger patients were more likely to be cared for by a specialized palliative care service, more often informed about imminent death as well as assessed for pain. For most national quality indicators, the goal level was not met. Only for the 'on demand prescription for pain', the goal level was reached.Conclusions: EOL care did not meet national quality indicators in this population-based data from Sweden, in particular in the elderly population. Elderly gynaecological cancer patients are at high risk of poorer EOL care without the involvement of specialized palliative care services. Palliative care services need to be implemented across all institutions of EOL care to ensure good and equal care.
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Affiliation(s)
- K. Lindemann
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - L. Martinsson
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - S. Kaasa
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - D. Lindquist
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
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Rose PG, Java JJ, Salani R, Geller MA, Alvarez A, Tewari KS, Bender DP, Mutch DG, Friedlander ML, Van Le L, Method MW, Hamilton CA, Lee RB, Wenham RM, Guntupalli SR, Markman M, Muggia FM, Armstrong DK, Bookman MA, Burger RA, Copeland LJ. Nomogram for Predicting Individual Survival After Recurrence of Advanced-Stage, High-Grade Ovarian Carcinoma. Obstet Gynecol 2019; 133:245-254. [PMID: 30633128 PMCID: PMC6551603 DOI: 10.1097/aog.0000000000003086] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To analyze clinical prognostic factors for survival after recurrence of high-grade, advanced-stage ovarian-peritoneal-tubal carcinoma and to develop a nomogram to predict individual survival after recurrence. METHODS We retrospectively analyzed patients treated in multicenter Gynecologic Oncology Group protocols for stage III and IV ovarian-peritoneal-tubal carcinoma who underwent primary debulking surgery, received chemotherapy with paclitaxel and a platinum compound, and subsequently developed recurrence. Prognostic factors affecting survival were identified and used to develop a nomogram, which was both internally and externally validated. RESULTS There were 4,739 patients included in this analysis, of whom, 84% had stage III and 16% had stage IV ovarian carcinoma. At a median follow-up of 88.8 months (95% CI 86.2-92.0 months), the vast majority of patients (89.4%) had died. The median survival after recurrence was 21.4 months (95% CI 20.5-21.9 months). Time to recurrence after initial chemotherapy, clear cell or mucinous histology, performance status, stage IV disease, and age were significant variables used to develop a nomogram for survival after recurrence, which had a concordance index of 0.67. The time to recurrence alone accounted for 85% of the prognostic information. Similar results were found for patients who underwent second look laparotomy and had a complete pathologic response or received intraperitoneal chemotherapy. CONCLUSION For individuals with advanced-stage ovarian carcinoma who recur after standard first-line therapy, estimated survivals after recurrence are closely related to the time to recurrence after chemotherapy and prognostic variables can be used to predict subsequent survival. CLINICAL TRIAL REGISTRATION ClinialTrials.gov, NCT00002568, NCT00837993, NCT00002717, NCT01074398, and NCT00011986.
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Affiliation(s)
- Peter G Rose
- Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH;
| | - James J Java
- NRG Oncology Statistics and Data Management Center, Roswell Park Cancer Institute, Buffalo, NY;
| | | | | | | | | | | | - David G Mutch
- Washington University School of Medicine, St. Louis, MO;
| | | | | | - Michael W Method
- Community Health Network and Indiana University School of Medicine, Indianapolis, IN;
| | | | | | | | | | | | | | | | | | - Robert A Burger
- University of Pennsylvania Medical Center, Philadelphia, PA:
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Sheu J, Palileo A, Chen MY, Hoepner L, Abulafia O, Kanis MJ, Lee YC. Hospice utilization in advanced cervical malignancies: An analysis of the National Inpatient Sample. Gynecol Oncol 2018; 152:594-598. [PMID: 30587442 DOI: 10.1016/j.ygyno.2018.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hospice services improve quality of life and outcomes for patients and caretakers, compared to inpatient mortality. This study identifies factors that exert the strongest influence on end-of-life care modalities in patients with cervical cancer. METHODS Admissions with a diagnosis of cervical cancer that were discharged to hospice or died in-hospital were identified in the National Inpatient Sample years 2007-2011, excluding admissions coded for hysterectomy. Logistic regression models were used to examine differences in age, race, length of stay, primary payer, hospital region, admission type, hospital bedsize, hospital teaching status, income quartile, and Elixhauser comorbidity index score between the groups. RESULTS 2073 admissions with a diagnosis of cervical cancer resulting in hospice discharge (n = 1290) or inpatient death (n = 783) were identified. Age (P = 0.01), hospital region (P = 0.01), length of hospitalization (P < 0.01), Elixhauser comorbidity index score (P = 0.03), and urban vs. rural location (P = 0.01) had a significant impact on disposition in univariate analysis. Admissions of patients categorized as Asian/Pacific Islander (OR = 2.24, 95% CI 1.11-4.49), hospitalizations lasting 0-3 days (OR = 1.57, 95% CI 1.21-2.03), and admissions in rural areas (OR = 1.62, 95% CI 1.12-2.36) had higher rates of in-hospital death compared to the reference groups. Patients aged 18-45 years (OR = 0.69, 95% CI 0.52-0.90) and those treated in the South (OR 0.59, 95% CI 0.45-0.77) and West (OR = 0.50, 95% CI 0.30-0.81) had lower odds ratios of inpatient mortality. CONCLUSION Modalities of care in terminal cervical cancer vary among sociodemographic and clinical factors. This data underscores the continued push for improved end-of-life care among cervical cancer patients and can guide clinicians in appropriate targeted counseling to increase utilization of hospice resources.
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Affiliation(s)
- Joanne Sheu
- Division of Gynecologic Oncology, SUNY Downstate Medical Center, United States of America.
| | - Albert Palileo
- Division of Gynecologic Oncology, SUNY Downstate Medical Center, United States of America
| | - Michael Y Chen
- College of Medicine, SUNY Downstate Medical Center, United States of America
| | - Lori Hoepner
- School of Public Health, SUNY Downstate Medical Center, United States of America
| | - Ovadia Abulafia
- Division of Gynecologic Oncology, SUNY Downstate Medical Center, United States of America
| | - Margaux J Kanis
- Division of Gynecologic Oncology, SUNY Downstate Medical Center, United States of America
| | - Yi-Chun Lee
- Division of Gynecologic Oncology, SUNY Downstate Medical Center, United States of America
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Schneiter MK, Karlekar MB, Crispens MA, Prescott LS, Brown AJ. The earlier the better: the role of palliative care consultation on aggressive end of life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients. Support Care Cancer 2018; 27:1927-1934. [PMID: 30209601 DOI: 10.1007/s00520-018-4457-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/30/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the role of specialty palliative care consultation (PCC) on end of life care outcomes among terminally ill gynecologic oncology patients. METHODS Retrospective chart review of currently deceased gynecologic oncology patients seen at a single, academic institution between October 2006 and October 2016. Clinical characteristics and outcomes were examined using descriptive statistics and logistic regression. RESULTS Two hundred and four patients were eligible. Forty-one percent underwent at least one marker of aggressive care at the end of life. Most (53%) had a PCC prior to death, and of these most were inpatient (89%). Patients with a PCC had higher odds of hospice enrollment before death (OR 2.55, p = 0.016) and higher odds of advance care planning documentation before death (OR 6.79, p = < 0.001). Among patients with an inpatient PCC, 44% underwent a marker of aggressive medical care at the end of life and 82% enrolled in hospice before death. Among patients with an outpatient PCC, 25% underwent a marker of aggressive medical care at the end of life and 92% enrolled in hospice before death. Patients with outpatient PCC were engaged in palliative care longer than patients with inpatient PCC (median 106 days vs. 33 days prior to death). CONCLUSIONS PCC increased hospice enrollment and advance care planning documentation. Patients with outpatient PCC had lower rates of aggressive medical care and higher rates of hospice enrollment when compared to inpatient PCC. Location of initial PCC plays an important role in end of life care outcomes.
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Affiliation(s)
- Mali K Schneiter
- Department of Obstetrics/Gynecology, Gynecologic Oncology, Vanderbilt University Medical Center, 1161 Medical Center Dr. MCN B1100, Nashville, TN, 37232, USA
| | - Mohana B Karlekar
- Department of Medicine and Biomedical Informatics, Palliative Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marta A Crispens
- Department of Obstetrics/Gynecology, Gynecologic Oncology, Vanderbilt University Medical Center, 1161 Medical Center Dr. MCN B1100, Nashville, TN, 37232, USA
| | - Lauren S Prescott
- Department of Obstetrics/Gynecology, Gynecologic Oncology, Vanderbilt University Medical Center, 1161 Medical Center Dr. MCN B1100, Nashville, TN, 37232, USA
| | - Alaina J Brown
- Department of Obstetrics/Gynecology, Gynecologic Oncology, Vanderbilt University Medical Center, 1161 Medical Center Dr. MCN B1100, Nashville, TN, 37232, USA.
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End-of-Life Care for Patients With Advanced Ovarian Cancer Is Aggressive Despite Hospice Intervention. Int J Gynecol Cancer 2018; 28:1183-1190. [DOI: 10.1097/igc.0000000000001285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Quality of life, symptoms and care needs in patients with persistent or recurrent platinum-resistant ovarian cancer: An NRG Oncology/Gynecologic Oncology Group study. Gynecol Oncol 2018; 150:119-126. [PMID: 29778506 DOI: 10.1016/j.ygyno.2018.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The goals of treating recurrent platinum-resistant ovarian cancer are palliative, aimed at reducing symptoms and improving progression free survival. A prospective trial was conducted to determine the prevalence and severity of symptoms, and associated care needs. METHODS Eligible women included those with persistent or recurrent platinum-resistant ovarian cancer with an estimated life expectancy of at least 6 months. The Needs at the End-of-Life Screening Tool (NEST), FACIT-Fatigue (FACIT-F), NCCN-FACT Ovarian Symptom Index [NFOSI-18]; Disease Related Symptoms (DRS), Treatment Side Effects (TSE), and Function/Well Being (F/WB) were collected at study entry, 3 and 6 months. RESULTS We enrolled 102 evaluable patients. Initiation of Do Not Resuscitate (DNR) discussions increased over time from 28% at study entry to 37% at 6 months. At study entry, the most common disease-related symptoms were fatigue (92%), worry (89%), and trouble sleeping (76%); 73% reported being "bothered by treatment side effects", which included nausea (41%) and hair loss (51%) neither of which changed over time. The most common NEST unmet needs were in the symptom dimension. The social dimension was associated with F/WB (p = 0.002) and FACIT-F (p = 0.006); symptoms were associated with DRS (p = 0.04), TSE (p = 0.03), and FACIT-F (p = 0.04); existential was not associated with any of the patient-reported symptoms; therapeutic was associated with F/WB (p = 0.02). CONCLUSIONS In patients nearing the end of life, there are significant associations between disease and treatment related symptoms and unmet patient needs, which do not change substantially over time. Careful exploration of specific end-of-life care needs can improve patient-centered care and QOL.
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17
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Predicting 6- and 12-Month Risk of Mortality in Patients With Platinum-Resistant Advanced-Stage Ovarian Cancer: Prognostic Model to Guide Palliative Care Referrals. Int J Gynecol Cancer 2018; 28:302-307. [PMID: 29360690 DOI: 10.1097/igc.0000000000001182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Predictive models are increasingly being used in clinical practice. The aim of the study was to develop a predictive model to identify patients with platinum-resistant ovarian cancer with a prognosis of less than 6 to 12 months who may benefit from immediate referral to hospice care. METHODS A retrospective chart review identified patients with platinum-resistant epithelial ovarian cancer who were treated at our institution between 2000 and 2011. A predictive model for survival was constructed based on the time from development of platinum resistance to death. Multivariate logistic regression modeling was used to identify significant survival predictors and to develop a predictive model. The following variables were included: time from diagnosis to platinum resistance, initial stage, debulking status, number of relapses, comorbidity score, albumin, hemoglobin, CA-125 levels, liver/lung metastasis, and the presence of a significant clinical event (SCE). An SCE was defined as a malignant bowel obstruction, pleural effusion, or ascites occurring on or before the diagnosis of platinum resistance. RESULTS One hundred sixty-four patients met inclusion criteria. In the regression analysis, only an SCE and the presence of liver or lung metastasis were associated with poorer short-term survival (P < 0.001). Nine percent of patients with an SCE or liver or lung metastasis survived 6 months or greater and 0% survived 12 months or greater, compared with 85% and 67% of patients without an SCE or liver or lung metastasis, respectively. CONCLUSIONS Patients with platinum-resistant ovarian cancer who have experienced an SCE or liver or lung metastasis have a high risk of death within 6 months and should be considered for immediate referral to hospice care.
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18
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Schulkes KJG, van Walree IC, van Elden LJR, van den Bos F, van Huis-Tanja L, Lammers JWJ, Ten Bokkel Huinink D, Hamaker ME. Chemotherapy and healthcare utilisation near the end of life in patients with cancer. Eur J Cancer Care (Engl) 2017; 27:e12796. [PMID: 29143390 DOI: 10.1111/ecc.12796] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 01/24/2023]
Abstract
The quality of medical care delivered to patients with cancer near the end of life is a significant issue. Previous studies have defined several areas suggestive of aggressive cancer treatment as potentially representing poor quality care. The primary objective of current analysis was to examine chemotherapy and healthcare utilisation in the last 3 months of life among patients with cancer that received palliative chemotherapy. Patients were selected from the hospital administration database of the Diakonessenhuis Utrecht, the Netherlands. Data were extracted from the medical files. A total of 604 patients were included for analysis (median age: 64 years). For 300 patients (50%) chemotherapy was given in the last 3 months (CT+). For 76% (n = 229) of CT+ patients unplanned hospital admissions were made in these last 3 months, compared to 44% (n = 133) of CT- patients (p < .001). Visits to the emergency room in last 3 months were made by 67% (n = 202) of CT+ patients compared to 43% (n = 132) of CT- patients (p < .001). Healthcare consumption was significantly higher in patients who received chemotherapy in the last 3 months of life. Being able to inform our patients about these aspects of treatment can help to optimise both the quality of life and the quality of dying in patients with cancer.
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Affiliation(s)
- K J G Schulkes
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands.,Department of Pulmonology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - I C van Walree
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - L J R van Elden
- Department of Pulmonology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - F van den Bos
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - L van Huis-Tanja
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - J-W J Lammers
- Department of Pulmonology, UMC Utrecht, Utrecht, The Netherlands
| | - D Ten Bokkel Huinink
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - M E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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19
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Kassianos AP, Ioannou M, Koutsantoni M, Charalambous H. The impact of specialized palliative care on cancer patients' health-related quality of life: a systematic review and meta-analysis. Support Care Cancer 2017; 26:61-79. [PMID: 28932908 DOI: 10.1007/s00520-017-3895-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/11/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Specialized palliative care (SPC) is currently underutilized or provided late in cancer care. The aim of this systematic review and meta-analysis is to critically evaluate the impact of SPC on patients' health-related quality of life (HRQoL). METHODS Five databases were searched through June 2016. Randomized controlled trials (RCTs) and prospective studies using a pre- and post- assessment of HRQoL were included. The PRISMA reporting statement was followed. Criteria from available checklists were used to evaluate the studies' quality. A meta-analysis followed using random-effect models separately for RCTs and non-RCTs. RESULTS Eleven studies including five RCTs and 2939 cancer patients published between 2001 and 2014 were identified. There was improved HRQoL in patients with cancer following SPC especially in symptoms like pain, nausea, and fatigue as well as improvement of physical and psychological functioning. Less or no improvements were observed in social and spiritual domains. In general, studies of inpatients showed a larger benefit from SPC than studies of outpatients whereas patients' age and treatment duration did not moderate the impact of SPC. Methodological shortcomings of included studies include high attrition rates, low precision, and power and poor reporting of control procedures. CONCLUSIONS The methodological problems and publication bias call for higher-quality studies to be designed, funded, and published. However, there is a clear message that SPC is multi-disciplinary and aims at palliation of symptoms and burden in line with current recommendations.
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Affiliation(s)
- Angelos P Kassianos
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Myria Ioannou
- Department of Psychology, University of Cyprus, Nicosia, Cyprus
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20
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Utsumi F, Kajiyama H, Niimi K, Sekiya R, Sakata J, Suzuki S, Shibata K, Mizuno M, Kikkawa F. Clinical significance and predicting indicators of post-cancer-treatment survival in terminally ill patients with ovarian cancer. J Obstet Gynaecol Res 2017; 43:365-370. [PMID: 28150408 DOI: 10.1111/jog.13219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/26/2016] [Accepted: 09/23/2016] [Indexed: 11/29/2022]
Abstract
AIM Women with ovarian cancer (OC) often experience relapse and receive further repetitive chemotherapy. The objective of this study was to overview the remaining survival time after the final chemotherapy and to examine influential clinicopathologic indicators in those patients. METHODS The medical charts of deceased OC patients who had died of the disease between 2003 and 2012 were retrospectively reviewed. We investigated post-cancer-treatment survival (PCS) defined as the interval between the date of the final chemotherapy and death. RESULTS In all, 77 patients were enrolled. Three patients (3.9%) had received chemotherapy in the last 2 weeks. Eight (10.4%), 28 (36.4%), and 44 (57.2%) patients had received chemotherapy in the last 30, 60, and 90 days, respectively. There were no differences in either survival after recurrence or overall survival between the shorter (<75 days) and longer (≥75 days) PCS groups. On the other hand, patients in the shorter PCS group had significantly fewer chances of referral to a hospice or home-care than those in the latter group (P = 0.035). In multivariable analysis, a poorer performance status, an elevated white blood cell count, and a higher C-reactive protein value were significantly correlated with a shorter PCS (P = 0.004, 0.006 and 0.027, respectively). CONCLUSION Half of the patients received chemotherapy within 75 days of death and we did not identify any survival benefit in patients who received chemotherapy near the end of life. We should provide information to patients about their prognosis and discuss the timing of withdrawal from chemotherapy from the early stage of their recurrence.
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Affiliation(s)
- Fumi Utsumi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Center for Postgraduate Clinical Training and Career Development, Nagoya University Hospital, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuichiro Sekiya
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Sakata
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyosumi Shibata
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mika Mizuno
- Department of Gynecology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28:456-69. [PMID: 27353273 DOI: 10.1093/intqhc/mzw060] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
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Affiliation(s)
- M Cardona-Morrell
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia
| | - Jch Kim
- School of Medicine, Ground floor, 30, Western Sydney University, Narellan Road & Gilchrist Drive, Campbelltown NSW 2560, Australia
| | - R M Turner
- School of Public Health and Community Medicine, Level 2, Samuels Building, Samuels Ave, The University of New South Wales, Kensington NSW 2033, Australia
| | - M Anstey
- Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Perth WA 6009, Australia
| | - I A Mitchell
- Intensive Care Unit, Building 12, Level 3, Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
| | - K Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia Intensive Care Unit, Level 2, Liverpool Hospital, Elizabeth St & Goulburn St, Liverpool NSW 2170, Australia
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Taylor JS, Brown AJ, Prescott LS, Sun CC, Ramondetta LM, Bodurka DC. Dying well: How equal is end of life care among gynecologic oncology patients? Gynecol Oncol 2016; 140:295-300. [PMID: 26706661 PMCID: PMC4724523 DOI: 10.1016/j.ygyno.2015.12.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients. METHODS This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fisher's exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis. RESULTS Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007). CONCLUSIONS Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.
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Affiliation(s)
- Jolyn S Taylor
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Alaina J Brown
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren S Prescott
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Charlotte C Sun
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lois M Ramondetta
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Diane C Bodurka
- The Department of Medical Education, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Hui D, dos Santos R, Reddy S, Nascimento MSDA, Zhukovsky DS, Paiva CE, Dalal S, Costa ED, Walker P, Scapulatempo HH, Dev R, Crovador CS, De La Cruz M, Bruera E. Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study. Palliat Med 2015; 29:826-33. [PMID: 25881622 DOI: 10.1177/0269216315583031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Limited information is available on the symptomatic complications that occur in the last days of life. AIM We documented the frequency, clinical course, and survival for 25 symptomatic complications among patients admitted to acute palliative care units. DESIGN Prospective longitudinal observational study. MEASUREMENTS Their attending physician completed a daily structured assessment of symptomatic complications from admission to discharge or death. SETTING/PARTICIPANTS We enrolled consecutive advanced cancer patients admitted to acute palliative care units at MD Anderson Cancer Center, USA, and Barretos Cancer Hospital, Brazil. RESULTS A total of 352 patients were enrolled (MD Anderson Cancer Center = 151, Barretos Cancer Hospital = 201). Delirium, pneumonia, and bowel obstruction were the most common complications, occurring in 43%, 20%, and 16% of patients on admission, and 70%, 46%, and 35% during the entire acute palliative care unit stay, respectively. Symptomatic improvement for delirium (36/246, 15%), pneumonia (52/161, 32%), and bowel obstruction (41/124, 33%) was low. Survival analysis revealed that delirium (p < 0.001), pneumonia (p = 0.003), peritonitis (p = 0.03), metabolic acidosis (p < 0.001), and upper gastrointestinal bleed (p = 0.03) were associated with worse survival. Greater number of symptomatic complications on admission was also associated with poorer survival (p < 0.001). CONCLUSION Symptomatic complications were common in cancer patients admitted to acute palliative care units, often do not resolve completely, and were associated with a poor prognosis despite active medical management.
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Affiliation(s)
- David Hui
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata dos Santos
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | - Suresh Reddy
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Donna S Zhukovsky
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Shalini Dalal
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | | | - Paul Walker
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Rony Dev
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Maxine De La Cruz
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Too much, too late: Aggressive measures and the timing of end of life care discussions in women with gynecologic malignancies. Gynecol Oncol 2015; 138:383-7. [DOI: 10.1016/j.ygyno.2015.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/01/2015] [Indexed: 11/23/2022]
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Abstract
There is evidence from some countries of a trend towards increasingly aggressive pharmacological treatment of patients with advanced, incurable cancer. To what extent should this be understood as a progressive development in which technological innovations address previously unmet needs, or is a significant amount of this expansion explained by futile or even harmful treatment? In this article it is argued that while some of this growth may be consistent with a progressive account of medicines consumption, part of the expansion is constituted by the inappropriate and overly aggressive use of drugs. Such use is often explained in terms of individual patient consumerism and/or factors to do with physician behaviour. Whilst acknowledging the role of physicians and patients' expectations, this paper, drawing on empirical research conducted in the US, the EU and the UK, examines the extent to which upstream factors shape expectations and drive pharmaceuticalisation, and explores the value of this concept as an analytical tool.
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Affiliation(s)
- Courtney Davis
- Department of Social Science, Health and Medicine, School of Social Science and Public Policy, King's College London, Strand, London WC2R 2LS, UK.
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Pirl WF, Greer JA, Irwin K, Lennes IT, Jackson VA, Park ER, Fujisawa D, Wright AA, Temel JS. Processes of discontinuing chemotherapy for metastatic non-small-cell lung cancer at the end of life. J Oncol Pract 2015; 11:e405-12. [PMID: 25829525 DOI: 10.1200/jop.2014.002428] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Administration of chemotherapy close to death is widely recognized as poor-quality care. Prior research has focused on predictors and outcomes of chemotherapy administration at the end of life. This study describes processes of chemotherapy discontinuation and examines their relationships with timing before death, hospice referral, and hospital death. PATIENTS AND METHODS We reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small-cell lung cancer who participated in a trial of early palliative care. Chemotherapy treatments during final regimen were qualitatively analyzed to identify categories of discontinuation processes. We then quantitatively compared predictors and outcomes of the process categories. RESULTS A total of 144 patients died, with 81 and 48 receiving intravenous (IV) and oral chemotherapies as their final regimen, respectively. Five processes were identified for IV chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later. Among patients receiving oral chemotherapy, 83.3% (40 of 48) were switched from IV to oral delivery as their final regimen, sometimes concurrent with or even after hospice referral. CONCLUSION Date of last chemotherapy is not a proxy for when a decision to stop treatment is made. Patients with metastatic non-small-cell lung cancer stop their final chemotherapy regimen via different processes, which significantly vary in time before death and subsequent end-of-life care.
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Affiliation(s)
- William F Pirl
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Joseph A Greer
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Kelly Irwin
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Inga T Lennes
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Vicki A Jackson
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Elyse R Park
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Alexi A Wright
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan
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Wright AA, Hatfield LA, Earle CC, Keating NL. End-of-life care for older patients with ovarian cancer is intensive despite high rates of hospice use. J Clin Oncol 2014; 32:3534-9. [PMID: 25287831 DOI: 10.1200/jco.2014.55.5383] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To date, few studies have examined end-of-life care for patients with ovarian cancer. One study documented increased hospice use among older patients with ovarian cancer from 2000 to 2005. We sought to determine whether increased hospice use was associated with less-intensive end-of-life medical care. PATIENTS AND METHODS We identified 6,956 individuals age ≥ 66 years living in SEER areas who were enrolled in fee-for-service Medicare, diagnosed with epithelial ovarian cancer between 1997 and 2007, and died as a result of ovarian cancer by December 2007. We examined changes in medical care during patients' last month of life over time. RESULTS Between 1997 and 2007, hospice use increased significantly, and terminal hospitalizations decreased (both P < .001). However, during this time, we also observed statistically significant increases in intensive care unit admissions, hospitalizations, repeated emergency department visits, and health care transitions (all P ≤ .01). In addition, the proportion of patients referred to hospice from inpatient settings rose over time (P = .001). Inpatients referred to hospice were more likely to enroll in hospice within 3 days of death than outpatients (adjusted odds ratio, 1.36; 95% CI, 1.12 to 1.66). CONCLUSION Older women with ovarian cancer were more likely to receive hospice services near death and less likely to die in a hospital in 2007 compared with earlier years. Despite this, use of hospital-based services increased over time, and patients underwent more transitions among health care settings near death, suggesting that the increasing use of hospice did not offset intensive end-of-life care.
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Affiliation(s)
- Alexi A Wright
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
| | - Laura A Hatfield
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Craig C Earle
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Nancy L Keating
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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Brown AJ, Sun CC, Prescott LS, Taylor JS, Ramondetta LM, Bodurka DC. Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients. Gynecol Oncol 2014; 135:244-8. [PMID: 25192878 DOI: 10.1016/j.ygyno.2014.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/24/2014] [Accepted: 08/27/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. METHODS Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007-2011 were identified. Statistical analyses included Wilcoxon-Mann-Whitney, Chi-square analysis, and multivariate analysis. RESULTS 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378days prior to death, respectively. CONCLUSIONS Many ovarian cancer patients underwent some form of aggressive medical care in the last 30days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.
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Affiliation(s)
- Alaina J Brown
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Tsubamoto H, Ito Y, Kanazawa R, Wada R, Hosoda Y, Honda O, Takeyama R, Sakane R, Wakimoto Y, Shibahara H. Benefit of palliative chemotherapy and hospice enrollment in late-stage ovarian cancer patients. J Obstet Gynaecol Res 2014; 40:1399-406. [PMID: 24605763 DOI: 10.1111/jog.12320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/09/2013] [Indexed: 12/25/2022]
Abstract
AIM The ideal timing for transition to best supportive care (BSC) for ovarian cancer patients is not clear. We retrospectively assessed the survival benefit of continuing chemotherapy and hospice enrollment in late-stage ovarian cancer patients. MATERIALS AND METHODS Eligibility criteria included platinum and taxane treatment, clinical progression within 6 months of the last platinum dose, and progression during chemotherapy. RESULTS Of the 55 eligible patients (median overall survival after first becoming refractory [1st Ref], 96 days), 22 received chemotherapy (Chemo group), two received radiation therapy, and 13 had medical contraindications for subsequent chemotherapy. The remaining 18 patients (BSC group) were compared with the Chemo group. The Chemo and BSC groups had similar background characteristics, except for the rate of consultation with a regional palliative care physician before or within 1 week of 1st Ref (9% vs 50%, respectively). In multivariate analysis, chemotherapy (hazard ratio 0.251, P = 0.005) and hospice enrollment (hazard ratio, 0.274, P = 0.023) were predictive factors of survival after 1st Ref. CONCLUSIONS Chemotherapy after 1st Ref can be offered and hospice enrollment during the terminal stages is encouraged for recurrent ovarian cancer patients.
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Affiliation(s)
- Hiroshi Tsubamoto
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Japan
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Havrilesky LJ, Fountain C. Can we maximize both value and quality in gynecologic cancer care? A work in progress. Am Soc Clin Oncol Educ Book 2014:e268-e275. [PMID: 24857112 DOI: 10.14694/edbook_am.2014.34.e268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Value is defined as desirable health outcomes achieved per monetary unit spent. Comparative effectiveness research and cost-effectiveness research are methods that have been developed to quantify effectiveness and value to inform management decisions. In this article we review the comparative and cost-effectiveness literature in the field of ovarian cancer treatment. Studies have shown that improved ovarian cancer survival is associated with complete primary surgical cytoreduction, with treatment at high volume facilities by subspecialist providers (gynecologic oncologists) and with National Comprehensive Cancer Network (NCCN) guideline-adherent care in both surgical staging and chemotherapy regimens. Intraperitoneal/intravenous chemotherapy (compared with intravenous alone) has been associated with improved survival and cost-effectiveness. Bevacizumab for primary and maintenance therapy has been found to not be cost-effective (even in selective subsets) despite a small progression-free survival (PFS) advantage. For platinum-sensitive recurrent ovarian cancer, secondary cytoreduction and platinum-based combinations are associated with improved overall survival (OS); several platinum-based combinations have also been found cost-effective. For platinum-resistant recurrence, single agent therapy and supportive care are cost-effective compared with combination therapies. Although little prospective clinical research has been done around end-of-life care, one study reported that for platinum-resistant ovarian cancer, palliative intervention would potentially reduce costs and increase quality adjusted life years compared with usual care (based on improvement in quality of life [QOL]). Overall, cost comparisons of individual chemotherapy regimens are highly dependent on market prices of novel therapeutic agents.
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Affiliation(s)
- Laura J Havrilesky
- From the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Cynthia Fountain
- From the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Havrilesky LJ. Palliative services enhance the quality and value of gynecologic cancer care. Gynecol Oncol 2014; 132:1-2. [DOI: 10.1016/j.ygyno.2013.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
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Nevadunsky NS, Gordon S, Spoozak L, Van Arsdale A, Hou Y, Klobocista M, Eti S, Rapkin B, Goldberg GL. The role and timing of palliative medicine consultation for women with gynecologic malignancies: association with end of life interventions and direct hospital costs. Gynecol Oncol 2013; 132:3-7. [PMID: 24183728 DOI: 10.1016/j.ygyno.2013.10.025] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 10/05/2013] [Accepted: 10/22/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Aggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies. METHODS A retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥ 30 days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission <3 days. Inpatient direct hospital costs were calculated for the last 30 days of life from accounting records. Data were analyzed using Fisher's Exact, Mann-Whitney U, Kaplan-Meier, and Student's T testing. RESULTS 49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0-3) versus 2 (range 0-6) p=0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30 days of life were lower for patients with timely consultation, $0 (range 0-28,019) versus untimely, $7729 (0-52,720), p=0.01. CONCLUSIONS Timely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.
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Affiliation(s)
- Nicole S Nevadunsky
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Sharon Gordon
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA
| | - Lori Spoozak
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA
| | - Anne Van Arsdale
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA
| | - Yijuan Hou
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merieme Klobocista
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Serife Eti
- Beth Israel Medical Center, Department of Palliative Medicine, New York, NY, USA
| | - Bruce Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gary L Goldberg
- Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Bronx, NY, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
OBJECTIVE There are limited data regarding the end-of-life care for women with gynecologic malignancies. We set out to generate pilot data describing the care that women with gynecologic malignancies received in the last 6 months of life. Patient demographics, patterns of care, and utilization of palliative medicine consultation services were evaluated. METHODS One hundred patients who died of gynecologic malignancies were identified in our institutional database. Only patients who had received treatment with a gynecologic oncologist within 1 year of death were included. Medical records were reviewed for relevant information. Data were abstracted from the electronic medical record, and analyses were made using Student t test and Mann-Whitney U test with SPSS software. RESULTS The mean age of patients was 60 years (range, 30-94 years). Racial/ethnic distribution was as follows: 38%, white; 34%, black; and 15%, Hispanic. Seventy-five percent of patients received chemotherapy within the last 6 months of life, and 30% received chemotherapy within the last 6 weeks of life. The median number of days hospitalized during the last 6 months of life was 24 (range, 0-183 days). During the last 6 months of life, 19% were admitted to the intensive care unit, 17% were intubated, 5% had terminal extubation, and 13% had cardiopulmonary resuscitative efforts. Sixty-four percent had a family meeting, 50% utilized hospice care, and 49% had palliative medicine consultations. There was a significant difference in hospice utilization when comparison was made between patients who had 14 days or more from consultation until death versus patients who had 14 days or less or no consultation, 21 (72%) versus 29 (41%), P = 0.004. Patients who were single were less likely to have a palliative medicine consultation, P = 0.005. CONCLUSIONS End-of-life care for patients with gynecologic malignancies often includes futile, aggressive treatments and invasive procedures. It is unknown whether these measures contribute to longevity or quality of life. These pilot data suggest that factors for implementation of timely hospice referral, family support, and legacy building should include specialists trained in palliative medicine.
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Lopez-Acevedo M, Lowery WJ, Lowery AW, Lee PS, Havrilesky LJ. Palliative and hospice care in gynecologic cancer: a review. Gynecol Oncol 2013; 131:215-21. [PMID: 23774302 DOI: 10.1016/j.ygyno.2013.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 06/06/2013] [Accepted: 06/07/2013] [Indexed: 12/25/2022]
Abstract
Despite the increasing availability of palliative care, oncology providers often misunderstand and underutilize these resources. The goals of palliative care are relief of suffering and provision of the best possible quality of life for both the patient and her family, regardless of where she is in the natural history of her disease. Lack of understanding and awareness of the services provided by palliative care physicians underlie barriers to referral. Oncologic providers spend a significant amount of time palliating the symptoms of cancer and its treatment; involvement of specialty palliative care providers can assist in managing the complex patient. Patients with gynecologic malignancies remain an ideal population for palliative care intervention. This review of the literature explores the current state of palliative care in the treatment of gynecologic cancers and its implications for the quality and cost of this treatment.
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Affiliation(s)
- Micael Lopez-Acevedo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
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Lopez-Acevedo M, Havrilesky LJ, Broadwater G, Kamal AH, Abernethy AP, Berchuck A, Alvarez Secord A, Tulsky JA, Valea F, Lee PS. Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer. Gynecol Oncol 2013; 130:156-61. [PMID: 23587882 DOI: 10.1016/j.ygyno.2013.04.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/03/2013] [Accepted: 04/07/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES (1) To describe the prevalence, timing and setting of documented end-of-life (EOL) discussions in patients with advanced ovarian cancer; and (2) to assess the impact of timing and setting of documented end-of-life discussions on EOL quality care measures. METHODS A retrospective study of women who died of ovarian cancer diagnosed between 1999 and 2008 was conducted. The following are the EOL quality measures assessed: chemotherapy in the last 14 days of life, >1 hospitalization in the last 30 days, >1 ER visit in the last 30 days, intensive care unit (ICU) admission in the last 30 days, dying in an acute care setting, admitted to hospice ≤3 days. RESULTS One hundred seventy-seven (80%) patients had documented end-of-life discussions. Median interval from EOL discussion until death was 29 days. Seventy-eight patients (44%) had EOL discussions as outpatient and 99 (56%) as inpatient. Sixty-four out of 220 (29%) patients' care did not conform to at least one EOL quality measure. An EOL discussion at least 30 days before death was associated with a lower incidence of: chemotherapy in the last 14 days of life (p=0.003), >1 hospitalization in the last 30 days (p<0.001), ICU admission in the last 30 days (p=0.005), dying in acute care setting (p=0.01), admitted to hospice ≤3 days (p=0.02). EOL discussion as outpatient was associated with fewer patients hospitalized >1 in the last 30days of life (p<0.001). CONCLUSIONS End-of-life care discussions are occurring too late in the disease process. Conformance with EOL quality measures can be achieved with earlier end-of-life care discussions.
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Affiliation(s)
- Micael Lopez-Acevedo
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Campion FX, Larson LR, Kadlubek PJ, Earle CC, Neuss MN. Advancing performance measurement in oncology: quality oncology practice initiative participation and quality outcomes. J Oncol Pract 2011; 7:31s-5s. [PMID: 21886517 PMCID: PMC3092462 DOI: 10.1200/jop.2011.000313] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2011] [Indexed: 01/17/2023] Open
Abstract
The American health care system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of health care. In 2006, the American Society for Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCO's QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the Fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% v 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% v 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.
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Affiliation(s)
- Francis X Campion
- Outcome Sciences, Cambridge, MA; American Society of Clinical Oncology, Alexandria, VA; Ontario Institute for Cancer Research; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Oncology Hematology Care, Cincinnati, OH
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Arriba LN, Fader AN, Frasure HE, von Gruenigen VE. A review of issues surrounding quality of life among women with ovarian cancer. Gynecol Oncol 2010; 119:390-6. [DOI: 10.1016/j.ygyno.2010.05.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/12/2010] [Accepted: 05/14/2010] [Indexed: 11/16/2022]
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Barbera L, Elit L, Krzyzanowska M, Saskin R, Bierman A. End of life care for women with gynecologic cancers. Gynecol Oncol 2010; 118:196-201. [DOI: 10.1016/j.ygyno.2010.04.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 03/25/2010] [Accepted: 04/14/2010] [Indexed: 11/15/2022]
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Friedlander M, Butow P, Stockler M, Gainford C, Martyn J, Oza A, Donovan HS, Miller B, King M. Symptom control in patients with recurrent ovarian cancer: measuring the benefit of palliative chemotherapy in women with platinum refractory/resistant ovarian cancer. Int J Gynecol Cancer 2010; 19 Suppl 2:S44-8. [PMID: 19955914 DOI: 10.1111/igc.0b013e3181bf7fb8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Most women with advanced ovarian cancer will relapse and subsequently develop platinum-resistant/refractory ovarian cancer. The benefit of treatment is currently based on objective response rates, which are a crude measure of benefit. It would be clinically meaningful if we were better able to measure the benefit of palliative therapy and, in particular, ascertain whether cancer-related symptoms improve with treatment and how this impacts on quality of life. This paper reviews the management of patients with platinum-resistant/refractory ovarian cancer and highlights the gaps in our knowledge and shortcomings with the current approaches to measure the benefit of treatment. The ultimate objective is to describe and encourage recruitment to the Gynecologic Cancer Intergroup study that has recently opened. This study will recruit a large number of patients from around the world in an effort to develop more robust instruments to measure the benefit of chemotherapy and to understand the impact of chemotherapy on symptom control and quality of life. In addition, this study will give us an insight into how all patients are managed rather than a select minority who are treated in clinical trials.
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Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010; 28:1203-8. [PMID: 20124172 DOI: 10.1200/jco.2009.25.4672] [Citation(s) in RCA: 582] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences. METHODS This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians. RESULTS Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences. CONCLUSION Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.
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Affiliation(s)
- Jennifer W Mack
- Dana-Farber Cancer Institute, Department of Pediatric Oncology, 44 Binney St-454, Boston, MA 02115, USA.
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Zacchetti A, Coliva A, Luison E, Seregni E, Bombardieri E, Giussani A, Figini M, Canevari S. 177Lu- labeled MOv18 as compared to 131I- or 90Y-labeled MOv18 has the better therapeutic effect in eradication of alpha folate receptor-expressing tumor xenografts. Nucl Med Biol 2009; 36:759-70. [DOI: 10.1016/j.nucmedbio.2009.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 05/13/2009] [Accepted: 05/15/2009] [Indexed: 01/29/2023]
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