Patterns of palliative care referral in ovarian cancer: A single institution 5 year retrospective analysis

Timing of Palliative Care, End-of-Life Quality Indicators, and Health Resource Utilization

Importance

Despite research supporting the benefits of early palliative care, timely initiation by gynecologic oncology patients is reportedly low, which may limit the effectiveness of palliative care.

Objective

To investigate the association of the timing of palliative care initiation with the aggressiveness of end-of-life care using established quality indicators among patients with ovarian cancer.

Design, Setting, and Participants

This population-based retrospective cohort study of ovarian cancer decedents used linked administrative health care data to identify palliative care provision across all health care sectors and health care professionals (specialist and nonspecialist) and end-of-life quality indicators in Ontario, Canada, from 2006 to 2018. Data analyses were performed July 12, 2024.

Main Outcomes and Measures

The primary outcome was the associations between the timing of palliative care and end-of-life quality indicators, including emergency department use, hospital or intensive care unit admission in the last 30 days of life, chemotherapy in last 14 days of life, death in the hospital, and a composite measure of aggressive care. Late palliative care was defined as 3 months or less prior to death.

Results

There were 8297 ovarian cancer decedents. Their mean (SD) age at death was 69.6 (13.1) years, and their mean (SD) oncologic survival was 2.8 (3.9) years. Among 3958 patients with known cancer stage, 3495 (88.3%) presented with stage III or IV disease. One-third of patients (2667 [32.1%]) received late palliative care in the final 3 months of life. Results of multivariable regression analysis indicated that any palliative care initiated earlier than 3 months before death was associated with lower rates of aggressive end-of-life care (odds ratio [OR], 0.47 [95% CI, 0.37-0.60]), death in hospital (OR, 0.54 [95% CI, 0.45-0.65]), and intensive care unit admission (OR, 0.46 [95% CI, 0.27-0.76]). Specialist palliative consultation from 3 months up to 6 monts before death was associated with decreased likelihood of late chemotherapy (OR, 0.46 [95% CI, 0.24-0.88]).

Conclusions

Findings from this cohort study suggested that early palliative care may be associated with less-aggressive end-of-life care than late palliative care. Implementation strategies for early palliative care initiation are needed to optimize care quality and health resource utilization at the end of life.

Symptom burden, palliative care knowledge, and palliative care needs in advanced gynecological cancer patients in Korea

Advanced gynecological cancer patients endure numerous symptoms resulting from both the disease itself and the treatments they undergo. This symptom burden significantly impacts the quality of life for both patients and their caregivers, as well as escalating medical costs. Palliative care presents a solution to alleviate these challenges. However, in Korea, there exists a low level of awareness regarding palliative care and consequently, a low utilization rate. Providing timely palliative care to advanced gynecological cancer patients in Korea necessitates a comprehensive understanding of their symptom burden, palliative care knowledge, and palliative care needs. However, no previous studies have addressed this critical issue. The purpose of this study is to determine the impact of advanced gynecological cancer on palliative care needs in Korea according to patient demographic and clinical characteristics, symptom burden, and palliative care knowledge. This study was a descriptive cross-sectional study of data from 115 participants with stage III or IV gynecological cancer, collected through an online questionnaire. The main variables were symptom burden (Functional Assessment of Cancer Therapy-General), palliative care knowledge (Palliative Care Knowledge Scale), and palliative care needs (Problems and Needs in Palliative Care questionnaire-short version). Multiple hierarchical regression analyses were used to determine the relationships between variables. Palliative care needs were divided into perceived problems and requests for professional support. The most common perceived problems were financial problems, psychological issues, and physical symptoms, and the most frequent requests for professional support were financial problems, psychological issues, and the need for information. The perceived problem score increased with age, not having surgical experience, and significant symptom burden. Additionally, the requests for professional support score rose in cases of ovarian cancer, not having surgical history, substantial symptom burden, and limited palliative care knowledge. Advanced gynecological cancer patients have palliative care needs that differ according to patient characteristics, symptom burden, and palliative care knowledge. Identifying factors influencing palliative care needs can aid clinicians in identifying target groups in need of palliative care and providing them with professional palliative care.

Multilevel Determinants of Palliative Care Referral in Women With Advanced Ovarian Cancer: A Scoping Review

CONTEXT

Receipt of palliative care (PC) has long been suggested in practice for patients with advanced cancer for improved quality of life, mood, and prolonged survival. However, PC referrals in women with ovarian cancer remain suboptimal.

OBJECTIVE

To consolidate existing literature on the multiple factors associated with PC referrals in women with advanced ovarian cancer and to better understand the contextual factors of PC referrals and frame receipt of PC using a socioecological model.

METHODS

A search of scientific databases was conducted, including PubMed, Embase, CINAHL Complete, and PsycINFO. Key search terms included "ovarian cancer" and "palliative care," and later refined to include advanced stages of the diagnosis. The reviewed articles included a focus on advanced ovarian cancer and reported demographic, medical/clinical, support, or system-level factors examined in the PC referral process.

RESULTS

Thirteen articles focused on the factors directly associated with PC referrals. Factors were categorized into different socioecological levels: tumor-level, intrapersonal, interpersonal, and environmental. Factors included tumor characteristics, age, marital status, medical condition, performance status, psychosocial status, support system, provider, and infrastructure. The patient's medical condition was the major component considered in PC referral and care transition.

CONCLUSION

Various factors in the socioecological framework suggest that the decision for PC referral could be multifactorial and influenced by factors beyond the medical condition and status. Future research should aim to understand the impact of various socioecological factors on PC referral and examine PC referral experiences from the patient's perspective.

Too Close for Comfort? Attitudes of Gynecologic Oncologists Toward Caring for Dying Patients

PURPOSE

To assess gynecologic oncologists' attitudes relating to palliative care referrals among advanced cancer patients.

METHODS

Gynecologic oncologists were surveyed using validated measures to assess stigmatizing attitudes toward palliative care, anticipated stigma of palliative care, acceptance of palliative care, and willingness to refer to palliative care. Descriptive statistics were calculated. Analysis was performed using linear regression.

RESULTS

1200 physicians received the survey and 108 (9%) completed it. Most were female (69.4%) and white (82.4%). Most practiced in academics (64.8%) in urban environments (71.3%). Respondents did not have anticipated stigma surrounding palliative care referral (mean score 1.89, range 1-7, higher score indicating more stigma), were accepting of palliative care (mean score 1.45, range 1-7, higher score indicating less acceptance), and were willing to refer patients to palliative care (mean score 5.75, range 1-7, higher score indicating more willingness to refer). Linear regression demonstrated females had less anticipated stigma surrounding palliative care (B = -.213, P = .04) and higher acceptance of palliative care (B = -.244, P = .01). Most surveyed derived satisfaction from work with advanced cancer patients (83%). Nineteen percent were depressed by managing advanced cancer patients. One fourth felt emotionally burned out by dealing with too many deaths.

CONCLUSIONS

Most gynecologic oncologists did not exhibit stigma surrounding palliative care and derive satisfaction from their work. Some gynecologic oncologists experience depression and burnout related to their profession. This close connection with patients as they transition to the end of life may take a toll on providers.

Incorporation of Palliative Care in Gynecologic Oncology

PURPOSE OF REVIEW

This review serves to provide clarity on the nature, scope, and benefits of early palliative care integration into the management of patients with gynecologic malignancies.

RECENT FINDINGS

There is increased recognition that timely referral to palliative care improves quality of life for patients and their families by providing goal-concordant care that reduces physical and emotional suffering and limits futile and aggressive measures at the end of life. Palliative care services rendered throughout the continuum of illness ultimately increase engagement with hospice services and drive down health expenditures. Despite these myriad benefits, misconceptions remain, and barriers to and disparities in access to these services persist and warrant continued attention. Palliative care should be offered to all patients with advanced gynecologic cancers early in the course of their disease to maximize benefit to patients and their families.

European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

BACKGROUND

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer.

OBJECTIVE

To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer.

METHODS

The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives.

RESULTS

The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Palliative Care Use in Advanced Cancer in the Garden State

BACKGROUND

Cancer is the second leading cause of death in the United States. Patients with metastatic cancer have a high symptom burden. Major global and domestic cancer care recommendations advise integration of palliative care services for these patients. Palliative care is specialized care that can decrease cost, improve symptom burden, and improve quality of life. Patient factors driving the use of palliative care remain poorly understood but may include both physiological and psychological needs, namely, pain and depression, respectively.

OBJECTIVE

The objective of this study was to identify patient-level predictors associated with inpatient palliative care use in patients with metastatic cancer.

METHODS

This was a secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to hospitalized adults with metastatic cancer in New Jersey. Descriptive statistics characterized the sample. Generalized linear modeling estimated the effects of pain and depression on the use of inpatient palliative care.

RESULTS

The sample included 28 697 hospitalizations for patients with metastatic cancer. Within the sample, 4429 (15.4%) included a palliative care consultation. There was a 9.3% documented occurrence of pain and a 10.9% rate of depression. Pain contributed to palliative care use, but depression was not predictive of an inpatient care consultation. Age, income category, and insurance status were significant factors influencing use.

CONCLUSION

Understanding demographic and clinical variables relative to palliative care use may help facilitate access to palliative care for adults experiencing metastatic cancer.

IMPLICATION FOR PRACTICE

Increased screening for pain and depression may expand palliative care use for adults with metastatic cancer receiving inpatient care.

Palliative care utilization across health sectors for patients with gynecologic malignancies in Ontario, Canada from 2006 to 2018

OBJECTIVE

Early palliative care (PC) is associated with improved patient quality of life, less aggressive end-of-life care, and prolonged survival. We evaluated patterns of PC delivery in gynecologic oncology.

METHODS

We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care data.

RESULTS

The cohort included 16,237 decedents; 51.1% died of ovarian cancer, 30.3% uterine cancer, 12.1% cervical cancer, and 6.5% vulvar/vaginal cancers. Palliative care was most often delivered in the hospital inpatient setting in 81%, and 53% received specialist PC. PC was first received during hospital admission in 53%, and by outpatient physician care in only 23%. Palliative care was initiated a median 193 days prior to death, with the lowest two quintiles initiating care ≤70 days before death. The average user of PC resources (third quintile) received 68 days of PC. While cumulative use of community PC gradually increased over the final year of life, institutional palliative care use exponentially rose from 12 weeks until death. On multivariable analyses, predictors of initiating palliative care during a hospital admission included age ≥70 years at death, ≤3 month cancer survival, having cervical or uterine cancer, not having a primary care provider, or being in the lowest 3 income quintiles.

CONCLUSION

Most palliative care is initiated and delivered during hospital admission, and is initiated late in a significant proportion. Strategies to increase access to anticipatory and integrated palliative care may improve the quality of the disease course and the end of life.

Palliative care from the perspective of cancer physicians: a qualitative semistructured interviews study

OBJECTIVE

Integrated palliative care for populations with cancer is now highly recommended. However, numerous physicians working in cancer care are still reluctant to refer patients to specialist palliative care teams. This study explores their perceptions of palliative care and factors influencing reasons to refer to specialist palliative care.

METHODS

We used a qualitative methodology based on semistructured interviews with physicians working in cancer care, in two tertiary hospitals and one comprehensive cancer centre with access to a specialist palliative care team. Forty-six physicians were invited and 18 interviews were performed until data saturation. Participants were mainly men, licensed in cancer care, 37.9 years old on average and had 13 years of professional experience. The length of interviews was on average 34 min (SD=3). Analysis was performed accordingly with the thematic analysis.

RESULTS

The data analysis found four themes: symptom management as a trigger, psychosocial support, mediation provided by interventions, and the association with terminal care or death. Palliative care integrated interventions were mainly perceived as holistic approaches that offered symptom management expertise and time. They were valued for helping in consolidating decision-making from a different or external perspective, or an 'outside look'. Several barriers were identified, often due to the confusion between terminal care and palliative care. This was further highlighted by the avoidance of the words 'palliative care', which were associated with death.

CONCLUSIONS

National policies for promoting palliative care seemed to have failed in switching oncologists' perception of palliative care, which they still consider as terminal care.

Palliative Medicine Referral and End-of-Life Interventions Among Racial and Ethnic Minority Patients With Advanced or Recurrent Gynecologic Cancer

BACKGROUND

Referral to palliative medicine (PM) has been shown to improve quality of life, reduce hospitalizations, and improve survival. Limited data exist about PM utilization among racial minorities with gynecologic malignancies. Our objective was to assess differences in palliative medicine referrals and end of life interventions (within the last 30 days of life) by race and ethnicity in a diverse population of gynecologic oncology patients.

METHODS

A retrospective cohort study of patients receiving gynecologic oncologic care at a tertiary referral center between 2017 - 2019 was conducted. Patients had either metastatic disease at the time of diagnosis or recurrence. Demographic and clinical data were abstracted. Exploratory analyses were done using chi-square and rank sum tests. Tests were two-sided with significance set at P < .05.

RESULTS

A total of 186 patients were included. Of those, 82 (44.1%) were referred to palliative medicine. Underrepresented minorities accounted for 47.3% of patients. English was identified as the primary language for 69.9% of the patients and Spanish in 24.2%. Over 90% of patients had insurance coverage. Ovarian cancer (37.6%) and uterine cancer (32.8%) were the most common sites of origin. Most patients (75%) had advanced stage at the time of diagnosis. Race and language spoken were not associated with referral to PM. Black patients were more likely to have been prescribed appetite stimulants compared to White patients (41% vs 24%, P = .038). Black patients also had a higher number of emergency department visits compared to White patients during the study timeframe. Chemotherapy in the last 30 days of life was also more likely to be given to Black patients compared to White (P = .019).

CONCLUSIONS

Race was associated with variation in interventions and healthcare utilization near end-of-life. Understanding the etiologies of these differences is crucial to inform interventions for care optimization as it relates specifically to the health of minority patients.

Cancer-related emergency and urgent care: expanding the research agenda

Purpose of review

Cancer-related emergency department (ED) visits often result in higher hospital admission rates than non-cancer visits. It has been estimated many of these costly hospital admissions can be prevented, yet urgent care clinics and EDs lack cancer-specific care resources to support the needs of this complex population. Implementing effective approaches across different care settings and populations to minimize ED and urgent care visits improves oncologic complication management, and coordinating follow-up care will be particularly important as the population of cancer patients and survivors continues to increase. The National Cancer Institute (NCI) and the Office of Emergency Care (OECR) convened a workshop in December 2021, “Cancer-related Emergency and Urgent Care: Prevention, Management, and Care Coordination” to highlight progress, knowledge gaps, and research opportunities. This report describes the current landscape of cancer-related urgent and emergency care and includes research recommendations from workshop participants to decrease the risk of oncologic complications, improve their management, and enhance coordination of care.

Recent findings

Since 2014, NCI and OECR have collaborated to support research in cancer-related emergency care. Workshop participants recommended a number of promising research opportunities, as well as key considerations for designing and conducting research in this area. Opportunities included better characterizing unscheduled care services, identifying those at higher risk for such care, developing care delivery models to minimize unplanned events and enhance their care, recognizing cancer prevention and screening opportunities in the ED, improving management of specific cancer-related presentations, and conducting goals of care conversations.

Summary

Significant progress has been made over the past 7 years with the creation of the Comprehensive Oncologic Emergency Research Network, broad involvement of the emergency medicine and oncology communities, establishing a proof-of-concept observational study, and NCI and OECR’s efforts to support this area of research. However, critical gaps remain.

Patterns of palliative care referral in platinum resistant ovarian cancer demonstrate reactive rather than proactive approach

•

Referral to palliative care within eight weeks of advanced cancer diagnosis is recommended.

•

Rates of palliative care referral in ovarian cancer patients are high compared with prior literature.

•

Timing of referral suggests a reaction to clinical decline, rather than proactive approach.

•

Diagnosis of platinum resistance should serve as a stimulus for palliative care referral.

Objective

To evaluate patterns of palliative care (PC) integration in patients with platinum resistant ovarian cancer.

Methods

Single institution retrospective study of patients with ovarian, tubal, or peritoneal high-grade carcinoma treated 2011–2020. Platinum resistance was identified by chemotherapy regimen or provider definition. Data was extracted evaluating treatment regimens, time to progression, PC and hospice referrals, and survival. Descriptive statistics and survival analyses were performed.

Results

We identified 258 patients with platinum resistant ovarian cancer. Median survival from diagnosis of platinum resistance was 15 months (range 0–161). Most (71 %) patients were referred to PC, with 43 % of referrals within 3 months of death. Fourteen percent of patients were referred directly to hospice without PC involvement. Of 46 patients living with platinum resistant disease, 93 % meet criteria for early PC referral, but less than half have seen PC. Median time from platinum resistance to PC referral was 9 months (range 0–157) and from PC referral to death was 3 months (range 0–110). Median time from platinum resistance to hospice referral was 7 months (range 1–57) and from hospice referral to death was < 1 month (range 0–12).

Conclusion

While rates of PC referral in our cohort are high compared with other single institution cohorts, timing of PC referral suggests referral patterns that are reactive to clinical decline rather than proactive as per national recommendations. A significant percentage of patients are directly referred to hospice for end-of-life care, reflecting missed opportunity for concurrent PC and oncology care earlier in the disease course. Diagnosis of platinum resistance should serve as a stimulus for PC involvement.

Opioid use and associated factors among pancreatic cancer patients diagnosed between 2007 and 2015

BACKGROUND

Opioid therapy provides essential pain relief for cancer patients. We used the population-based Surveillance Epidemiology and End Results (SEER) linked with Medicare database to identify the patterns of opioid use and associated factors in pancreatic adenocarcinoma cancer patients 66 years or older.

PATIENTS AND METHODS

We assessed opioid types, dispensed days, opioid uptake rates, and factors associated with opioid use after pancreatic adenocarcinoma cancer diagnosis in Medicare beneficiaries between 2007 and 2015 from the SEER-Medicare data. Multivariable regression analysis was used to adjust for a variety of patient-related factors.

RESULTS

We identified a cohort of 10,745 pancreatic cancer patients with a median age of 76 years old and median survival of 7 months; 75% of patients-initiated opioids after cancer diagnosis. African Americans had the lowest rate of opioid use of 69.1% compared with all other race/ethnicity groups at around 75%. No significant yearly trend of prescribing opioids was detected. Hydrocodone was the most frequently prescribed opioid type. Regression analysis revealed that age ≤80 years, residing in Southern or Western SEER registries, residing in urban/less urban versus big metro areas, having stage IV cancer at diagnosis, longer survival time, and undertaking cancer-directed treatment or using palliative care were positively associated with opioid initiation, more prescribed opioid types, and higher opioid doses.

DISCUSSION

While a range of sociodemographic variables were associated with opioid use in unadjusted analysis, the associations between race/ethnicity, gender, and socioeconomic status with opioid initiation disappeared when sociodemographic factors, tumor characteristics, and cancer treatment were adjusted.

CONCLUSION

Health care professionals' opioid prescription pattern for pancreatic cancer patients does not parallel the U.S. opioid epidemic. Racial/ethnic disparities in opioid treatment were not identified.

Intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

Objective

The association of primary oncologist specialty, medical oncology versus gynecologic oncology, on intensity of care at the end of life in elderly patients with gynecologic cancer is unclear.

Methods

This retrospective cohort study used Surveillance, Epidemiology and End Results-Medicare (SEER-M) data. Subjects were fee-for-service Medicare enrollees aged 65 years and older who died of a gynecologic cancer between January 2006 and December 2015. The primary outcome was a composite score for high-intensity care received in the last month of life. Secondary outcomes included invasive procedures and Medicare spending in the last month of life. Simple and multivariable linear and logistic regression analyses evaluated differences in outcomes by primary oncologist specialty. Linear regressions were repeated after creating a more similar control group through nearest-neighbor propensity score matching.

Results

Of 12 189 patients, 7705 (63%) had a medical primary oncologist in the last year of life. In adjusted analyses, patients with a gynecologic versus medical primary oncologist received lower rates of high-intensity end-of-life care (53.9% vs 56.6%; p=0.018). Results were similar for the propensity score-matched cohorts. However, having a gynecologic versus medical primary oncologist was associated with higher rates of invasive procedures in the last month of life (43% vs 41%; p=0.014) and higher Medicare spending ($83 859 vs $74 849; p=0.004).

Conclusions

Both specialties engage in overall high levels of intense end-of-life care, with differences by specialty in aspects of aggressive care and spending at the end of life. Physician-level training could be a target for educational or quality improvement initiatives to improve end-of-life cancer care delivery.

Anti-oncogenic PTEN induces ovarian cancer cell senescence by targeting P21

Deletion and mutation of phosphatase and tensin homolog deleted on chromosome10 (PTEN) are closely associated with the occurrence of tumors. Tumor suppressor gene PTEN mutation plays an important role in the pathogenesis of ovarian cancer. However, it has been unclear whether it can regulate the senescence of ovarian cancer cells. We speculated that PTEN might inhibit the occurrence and development of ovarian cancer by promoting the expression of P21. We found that the expression of TRIM39 in human ovarian cancer was significantly diminished. In SKOV3 cells treated with naringin, the expression of TRIM39, which binds P21 and inhibits P21 degradation, was significantly elevated. Real‐time polymerase chain reaction (PCR), Western blot, and immunofluorescence were used to detected the expression of PTEN, p21, and TRIM39, β‐galactosidase Staining was used to detect cell senescence, Ki67 staining was used to observe cell proliferation, Trim39 interference or overexpression assay was used to detect its function. We speculated that PTEN might promote SKOV3 cell senescence by increasing TRIM39 expression and decreasing P21 degradation. Furthermore, by interfering with TRIM39 in SKOV3 cells, we found that the expression of P21 was downregulated, and the number of senescent SKOV3 cells decreased. With overexpression of TRIM39 in SKOV3 cells, the expression of P21 was upregulated, and the number of senescent SKOV3 cells increased. When naringin, a PTEN agonist, was added to SKOV3 cells in which TRIM39 protein was interfered with, the expression of P21 was significantly lower than that in the control group, and the number of senescent ovarian cancer cells was significantly diminished. Our results indicated that PTEN maintained the stability of P21 and decreased the degradation of P21 by increasing TRIM39 expression, thus promoting the senescence of SKOV3 cells, and PTEN maintained the stability of p21 and promoted the aging of SKOV3 cells might be a novel therapeutic target for ovarian cancer.

"I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments

BACKGROUND

National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory.

OBJECTIVE

To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites.

METHODS

A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis.

RESULTS

Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity).

CONCLUSIONS

The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.

Palliative care utilization in calciphylaxis: a single-center retrospective review of 121 patients (1999-2016)

BACKGROUND

Calciphylaxis is a debilitating dermatological condition associated with high rates of morbidity and mortality. Palliative care offers a multidisciplinary approach to addressing symptoms and goals of care in patients with serious medical diagnoses. Involvement of palliative services for calciphylaxis is infrequently reported in the literature. The purpose of this report is to assess rates of palliative and pain consultation for patients with calciphylaxis.

METHODS

This is a comprehensive, single-institution retrospective chart review of 121 eligible patients with a diagnosis of calciphylaxis treated at Mayo Clinic in Rochester, Minnesota, from 1999 to 2016. Inclusion criteria were an indisputable diagnosis of calciphylaxis based on clinical, histopathologic, and radiographic features. One hundred twenty-one patients met inclusion criteria.

RESULTS

Fifty-one patients (42%) received either a palliative (n = 15) or pain (n = 20) consultation, or both (n = 16). Patients with a palliative care consultation were younger compared with those without (mean ages 57 vs. 62 years, P = 0.046). In 104 patients (86%), psychiatric symptoms were not assessed.

CONCLUSIONS

In this cohort of patients with calciphylaxis, the majority do not receive palliative and pain care consultations. Psychiatric complications are inconsistently addressed. These observations highlight practice gaps in the care of patients with calciphylaxis.

Palliative care among adult cancer survivors: Knowledge, attitudes, and correlates

OBJECTIVE

Palliative care (PC) is patient and family-centered supportive care intended to improve symptom management, reduce caregiver burden, coordinate care, and improve quality of life for patients diagnosed with serious illness. Optimally, PC is begun close to initial diagnosis and delivered in synchrony with disease-specific treatment until symptom relief or patient death. The purpose of this study was to examine cancer survivors' knowledge and perceptions of PC using a nationally representative sample of US adults from the Health Information National Trends Survey (HINTS).

METHOD

A total of 593 HINTS respondents reported a personal history of cancer and were included in the sample (55.56% female; mean age of 65.88 years, SD = 18.21; mean time from diagnosis 13.83 years, SD = 18.21). Weighted logistic regression models were conducted to identify correlates of PC knowledge.

RESULTS

Of the 593 cancer survivors in the sample, 66% (N = 378) reported that they had never heard of PC, 18% (N = 112) reported knowing a little bit about PC, and 17% (N = 95) reported knowing what PC is and could explain it to someone else. In multivariable analysis, survivors of color (Hispanic/Latino, Black, Asian, American Indian, and Pacific Islander), males, and those less educated were significantly less likely to report knowledge of PC. Among survivors who did report knowledge of PC, a lack of distinction between differing modes of supportive care exists.

SIGNIFICANCE OF RESULTS

These findings suggest a need to increase PC knowledge among cancer survivors with the ultimate goal of addressing disparities in PC acceptance and utilization.

Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004-2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III-IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53-2.12), and cervical (aOR: 1.45,95% CI: 1.26-1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48-0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60-0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58-0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.

Acceptability and Feasibility of Early Palliative Care Among Women with Advanced Epithelial Ovarian Cancer: A Randomized Controlled Pilot Study

OBJECTIVE

To evaluate the acceptability of early palliative care (EPC) among patients with advanced ovarian cancer and to determine the feasibility of larger-scale phase III trials.

METHODS

We performed a randomized controlled pilot study of adult women (>18 years) with pathologically confirmed epithelial ovarian cancer that had recurred or progressed on first-line therapy and had no immediate need for palliative care. We randomly assigned patients to either EPC or standard oncologic care (SOC), and collected patient-reported outcomes (PRO) at baseline, 3 months, and 6 months; end-of-life care quality indicators were collected at study completion. Study endpoints were rates of enrollment, EPC adherence, and PRO completion.

RESULTS

Of 32 eligible patients approached, 23 enrolled (72%; 95% CI 53-86) and were randomly assigned to either EPC (n = 12) or SOC (n = 11). At baseline, participants had poor physical and emotional wellbeing, high rates of depression (65%), and understood that their disease was not curable (87%). Eleven patients (92%; 95% CI 62-100) attended their EPC consultation, and all visits took place within 4 weeks of enrollment. However, PRO completion was low due to deaths by 3 (5/23) and 6 months (9/23).

CONCLUSION

Patients had accurate perceptions of their disease status, were willing to be randomly assigned to EPC, and attended scheduled appointments. However, a definitive trial in this group is not feasible without major adjustments to eligibility criteria and a multicentre, international effort. We propose that EPC be considered routinely at progression or recurrence given patients' symptom burden and clear acceptance of the intervention, as well as evidence of benefit from adequately powered trials in other malignancies.

Sources of Palliative Care Knowledge Among Patients With Advanced or Metastatic Gynecologic Cancer

CONTEXT

A minority of patients with advanced or metastatic gynecologic cancer utilize palliative care and lack of knowledge may be a barrier to receiving palliative care services.

OBJECTIVES

To identify sources used by patients with advanced or metastatic gynecologic cancer to learn about palliative care and evaluate for differences in knowledge about palliative care and palliative care utilization by knowledge source.

METHODS

Patients with gynecologic cancer receiving treatment for advanced or metastatic gynecologic cancer at a single academic medical center were surveyed about their awareness of and knowledge about palliative care. Medical chart review was conducted.

RESULTS

Of the 111 women surveyed, 70 had heard of palliative care (63%). Sixty-eight specified from where they learned of palliative care: cancer care (n = 28; 41.2%), word of mouth (n = 26; 38.2%), work (n = 6; 8.8%), self-education (n = 4; 5.9%), personal experience (n = 2; 2.9%), or do not know (n = 2; 2.9%). Knowledge about palliative care (P = 0.35) and palliative care utilization (P = 0.81) did not differ by awareness of palliative care.

CONCLUSION

Most women receiving treatment for advanced gynecologic cancer have heard of palliative care from sources other than their cancer care providers. Knowledge about palliative care and source of knowledge about palliative care were not associated with palliative care utilization. Awareness of palliative care and palliative care utilization may be improved by increasing the low rate of health provider-based education and engaging cancer patients' social networks.

Epigenetic Mechanisms beyond Tumour-Stroma Crosstalk

Despite cancer having been usually considered the result of genetic mutations, it is now well established that epigenetic dysregulations play pivotal roles in cancer onset and progression. Hence, inactivation of tumour suppressor genes can be gained not only by genetic mutations, but also by epigenetic mechanisms such as DNA methylation and histone modifications. To occur, epigenetic events need to be triggered by genetic alterations of the epigenetic regulators, or they can be mediated by intracellular and extracellular stimuli. In this last setting, the tumour microenvironment (TME) plays a fundamental role. Therefore, to decipher how epigenetic changes are associated with TME is a challenge still open. The complex signalling between tumour cells and stroma is currently under intensive investigation, and most of the molecules and pathways involved still need to be identified. Neoplastic initiation and development are likely to involve a back-and-forth crosstalk among cancer and stroma cells. An increasing number of studies have highlighted that the cancer epigenome can be influenced by tumour microenvironment and vice versa. Here, we discuss about the recent literature on tumour-stroma interactions that focus on epigenetic mechanisms and the reciprocal regulation between cancer and TME cells.

Frequency and Characteristics of First-Time Palliative Care Referrals During the Last Day of Life

CONTEXT

Palliative care referrals (PCRs) improve symptom management, provide psychosocial and spiritual support, clarify goals of care, and facilitate discharge planning. However, very late PCR can result in increased clinician distress and prevent patients and families from benefiting from the full spectrum of interdisciplinary care.

OBJECTIVES

To determine the frequency and predictors of PCR within 24 hours of death.

METHODS

Consecutive first-time inpatient PCR from September 1, 2013 to August 31, 2017 was identified to determine the frequency and predictors of referrals within 24 hours of death. We compared the clinical characteristics with a random sample of patients discharged alive or died more than 24 hours after first-time PCR as a control, stratified by year of consult in a 1:1 ratio.

RESULTS

Of 7322 first-time PCRs, 154 (2%) died within 24 hours of referral. These patients were older (P = 0.003) and had higher scores for depression (P = 0.0009), drowsiness (P = 0.02), and shortness of breath (P = 0.008) compared with a random sample of 153 patients discharged alive or died more than 24 hours after first-time PCR. Patients who received a PCR within 24 hours of death were more likely than the control group to have Eastern Cooperative Oncology Group 4 (95% vs. 25%, P < 0.0001), delirium (89% vs. 17%, P < 0.0001), do-not-resuscitate code status (81% vs. 18%, P < 0.0001), and hematologic malignancies (39% vs. 16%, P < 0.0001). In the multivariate analysis, depression (odds ratio [OR] 1.4; P = 0.005), do-not-resuscitate code status (OR 9.1; P = 0.003), and Eastern Cooperative Oncology Group 4 (OR 9.8; P = 0.003) were independently associated with first-time PCR within 24 hours of death.

CONCLUSION

Although only a small proportion of first-time PCR occurred in the last 24 hours of life, the patients had a significant amount of distress, indicating a missed opportunity for timely palliative care intervention. These sentinel events call for specific guidelines to better support patients, families, and clinicians during this difficult time. Further research is needed to understand how to minimize very late PCR.

Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care

BACKGROUND

Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence.

MATERIALS AND METHODS

Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral.

RESULTS

Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites.

CONCLUSIONS

Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care.

IMPLICATIONS FOR PRACTICE

Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

Systemic Anti-Cancer Therapy Use in Palliative Care Outpatients With Advanced Cancer

PURPOSE

To evaluate factors associated with continuation of systemic anti-cancer therapy (SACT) after palliative care consultation, and SACT administration in the last 30 days of life, in outpatients with cancer referred to palliative care. Timing of referral was of particular interest.

METHODS

Patient, disease, and treatment-related factors associated with SACT before and after palliative care, and in the last 30 days of life, were identified using 3-level multinomial logistic regression. Referral to palliative care was categorized by time from death as early (>12 months), intermediate (6-12 months), and late (≤6 months).

RESULTS

Of the 337 patients, 240 (71.2%) received SACT for advanced cancer; of these, 126 (52.5%) received SACT only prior to palliative care while 114 (47.5%) also received SACT afterward. Only 35/337 (10.4%) received SACT in the last 30 days of life. On multivariable analysis, factors associated with continuing SACT after palliative care consultation were a cancer diagnosis for <1 year (OR 3.09, p = 0.01), breast primary (OR 11.88, p = 0.0008), and early (OR 28.8, p < 0.001) or intermediate (OR 6.67, p < 0.001) referral timing. No factors were significantly associated with receiving SACT in the last 30 days versus earlier, but the median time from palliative care referral to death in those receiving SACT in the last 30 days versus stopping SACT earlier was 1.78 versus 4.27 months.

CONCLUSION

Patients who received SACT following palliative care consultation were more likely to be referred early; however, patients receiving SACT in their last 30 days tended to be referred late.

Palliative care referral patterns and measures of aggressive care at the end of life in patients with cervical cancer

INTRODUCTION

Fifteen per cent of women with cervical cancer are diagnosed with advanced disease and carry a 5 year survival rate of only 17%. Cervical cancer may lead to particularly severe symptoms that interfere with quality of life, yet few studies have examined the rate of palliative care referral in this population. This study aims to examine the impact of palliative care referral on women who have died from cervical cancer in two tertiary care centers.

METHODS

We conducted a retrospective review of cervical cancer decedents at two tertiary institutions from January 2000 to February 2017. We examined how aggressive measures of care at the end of life, metrics defined by the National Quality Forum, interacted with clinical variables to understand if end-of-life care was affected. Univariate and multivariate parametric and non-parametric testing was used, and linear regression models were generated to determine unadjusted and adjusted associations between aggressive measures of care at the end of life with receipt of palliative care as the main exposure.

RESULTS

Of 153 cervical cancer decedents, 73 (47%) received a palliative care referral and the majority (57%) of referrals occurred during an inpatient admission. The median time from palliative care consultation to death was 2.3 months and 34% were referred to palliative care in the last 30 days of life. Palliative care referral was associated with fewer emergency department visits (OR 0.18, 95% CI 0.05 to 0.56), inpatient stays (OR 0.21, 95% CI 0.07 to 0.61), and intensive care unit admissions (OR 0.24, 95% CI 0.06 to 0.93) in the last 30 days of life. Palliative care did not affect chemotherapy or radiation administration within 14 days of death (p=0.36). Women evaluated by palliative care providers were less likely to die in the acute care setting (OR 0.19, 95% CI 0.07 to 0.51).

DISCUSSION

In two tertiary care centers, less than half of cervical cancer decedents received palliative care consultations, and those referred to palliative care were often evaluated late in their disease course. Palliative care utilization was also associated with a lower incidence of poor-quality end-of-life care.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BACKGROUND

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

MATERIALS AND METHODS

We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.

CONCLUSION

"Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

IMPLICATIONS FOR PRACTICE

Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

Palliative versus hospice care in patients with cancer: a systematic review

BACKGROUND

Guidelines recommend an early access to specialised palliative medicine services for patients with cancer, but studies have reported a continued underuse. Palliative care facilities deliver early care, alongside antineoplastic treatments, whereas hospice care structures intervene lately, when cancer-modifying treatments stop.

AIM

This review identified factors associated with early and late interventions of specialised services, by considering the type of structures studied (palliative vs hospice care).

DESIGN

We performed a systematic review, prospectively registered on PROSPERO (ID: CRD42018110063).

DATA SOURCES

We searched Medline and Scopus databases for population-based studies. Two independent reviewers extracted the data and assessed the study quality using Joanna Briggs Institute critical appraisal checklists.

RESULTS

The 51 included articles performed 67 analyses. Most were based on retrospective cohorts and US populations. The median quality scores were 19/22 for cohorts and 15/16 for cross-sectional studies. Most analyses focused on hospice care (n=37). Older patients, men, people with haematological cancer or treated in small centres had less specialised interventions. Palliative and hospice facilities addressed different populations. Older patients received less palliative care but more hospice care. Patients with high-stage tumours had more palliative care while women and patients with a low comorbidity burden received more hospice care.

CONCLUSION

Main disparities concerned older patients, men and people with haematological cancer. We highlighted the challenges of early interventions for older patients and of late deliveries for men and highly comorbid patients. Additional data on non-American populations, outpatients and factors related to quality of life and socioeconomic status are needed.

Palliative treatment for bowel obstruction in ovarian cancer: a meta-analysis

OBJECTIVE

To comprehensively evaluate and compare outcomes of surgical versus nonsurgical palliative interventions for bowel obstruction due to ovarian cancer.

METHODS

Studies were obtained from database search systems of Pubmed, Medline, Wiley, Springerlink, Kluwer, Web of science and Science direct. Data were analyzed by the meta-analysis method and the random-effect or fixed-effect model. The heterogeneity between the studies was evaluated by I² index and the data were analyzed using STATA version 14.1.

RESULTS

12 studies involving 2778 cases of bowel obstruction in ovarian cancer were included, including 1225 cases of surgery and 1553 cases of palliative nonsurgical treatment. Surgery group had significantly higher remission rate of bowel obstruction (OR = 0.350, 95% CI 0.067-1.819, P = 0.000),but had no manifesting difference in the recurrence rate compared no-surgery group (RR = 0.88, 95% CI 0.76-1.03, P = 0.106). In 30-day mortality rate, surgery group had higher mortality rate (RR = 0.453, 95% CI 0.161-1.272, P = 0.000). But, surgical treatment can markedly prolong survival period (HR = 0.333, 95% CI 0.275-0.390, P = 0.000) compared nonsurgical treatment.

CONCLUSIONS

Surgery can significantly relieve the symptom of intestinal obstruction, prolonging the survival period, but had no impact on the recurrence. Compared with no-surgery group, surgery group suffered higher 30-day mortality.

Timing of palliative care access and outcomes of advanced cancer patients referred to an inpatient palliative care consultation team in Brazil

OBJECTIVE

Little is known about the outcomes of cancer patients referred to palliative care (PC) teams in developing countries. Our aim was to examine the timing of PC access and outcomes of patients with advanced cancer referred to an inpatient PC consultation team in Brazil.

METHOD

Retrospective study of consecutive patients with advanced cancer admitted to a tertiary care general hospital (April 2015-December 2016) and referred for the first time to an inpatient PC consultation team. Patients' demographics, clinical features, time from first consult to death or discharge, and outcomes on medication use, clinical interventions, and end-of-life preferences were retrieved. An analysis was performed before and after PC.

RESULT

One hundred eleven patients were included. Median age was 68; 72% had an Eastern Cooperative Oncology Group performance status ≥3. The median timing of PC access was 9 days (first interquartile = 3, third interquartile = 19). The use of analgesics (from 75% to 85%, p = 0.001) and opioids (from 50% to 73%, p < .001) increased. A lower proportion was receiving antibiotics (68% vs 48%, p < 0.001), thromboprophylaxis (44% vs 26%, p < 0.001), antihypertensives (28% vs 15%, p = 0.001), and antiemetic agents (64% vs 54%, p = 0.027). Chemotherapy use was lower (39-25%, p < 0.001). More patients had an end-of-life preference (39% to 25%, p < 0.001) and were not willing to receive intubation (32% vs 60%, p < 0.001), intensive care treatment (30% vs 55%, p < 0.001), cardiopulmonary resuscitation (35% vs 62%, p < 0.001), and artificial nutrition (22% vs 34%, p < 0.001).

SIGNIFICANCE OF RESULTS

Although PC referrals occurred exceedingly late during the cancer disease trajectory, positive changes were observed in medication profiles, clinical interventions use, and end-of-life preferences of patients with advanced cancer referred to a specialized inpatient PC consultation team in Brazil. Further efforts are needed to improve early palliative cancer care in developing countries.

Clinical trial participation and aggressive care at the end of life in patients with ovarian cancer

OBJECTIVES

In non-gynecologic cancers, clinical trial participation has been associated with aggressive care at the end of life. The objective of this investigation was to examine how trial participation affects end of life outcomes in patients with ovarian cancer.

METHODS

In a retrospective review of women diagnosed with ovarian cancer at our institution between January 2010 and December 2015, we collected variables identified by the National Quality Forum as measures of aggressive end of life care including chemotherapy in the last 14 days of life, intensive care unit (ICU) admission in the last 30 days of life, or death in the acute care setting. Trials investigating medications but not surgical interventions were included. The primary outcome of this study was the association between trial participation and the National Quality Forum measures of aggressive end of life care in ovarian cancer decedents. Data were analyzed with univariable and multivariable parametric and non-parametric testing, and time to event outcomes were analyzed using the Kaplan-Meier method and Cox's proportional hazard models.

RESULTS

Among 391 women treated for ovarian cancer, 62 patients (16%) participated in a clinical trial. Patients enrolled in clinical trials were more likely to have chemotherapy administered within 14 days of death; however, no association was found with other metrics of aggressive care at the end of life including the initiation of a new chemotherapy regimen in the last 30 days of life, ICU admissions, and death in an acute care setting. Among patients with recurrent ovarian cancer, median overall survival for trial participants was 57 months compared with only 31 months in non-trial participants (p<0.001).

CONCLUSIONS

In patients with ovarian cancer, clinical trial enrollment is associated with chemotherapy administration within 14 days of death, but not other measures of aggressive care at the end of life. Given the importance of clinical trial participation in improving care for women with ovarian cancer, this study suggests that concerns regarding aggressive care prior to death should not limit clinical trial participation.