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Tolppanen AM, Lamminmäki A, Länsimies H, Kataja V, Tyynelä-Korhonen K. Trends in end-of-life decisions among patients dying in a university hospital oncology ward after implantation of a palliative outpatient clinic. Acta Oncol 2022; 61:881-887. [PMID: 35467470 DOI: 10.1080/0284186x.2022.2063068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The need for high quality palliative care at end-of-life has been increasingly recognized while regional differences exist in its quality and availability. Basic palliative care is given by oncologists at any stage of the disease, but this does not cover the high need for specialized palliative care. The aim of this study was to assess the trends in end-of-life decisions among patients dying in a university hospital oncology ward before and after the implementation of a palliative outpatient clinic. MATERIAL AND METHODS The study population consists of all patients who died in the Kuopio University Hospital oncology ward between 1.1.2010-31.10.2011 and 1.1.2012-31.12.2018. The palliative outpatient clinic was established and set up in November - December 2011. Data on inpatient stays, cancer treatments, treatment decisions, and some background factors were retrieved from electronic records. RESULTS The study population totaled 644 patients dying in the oncology ward at KUH (57.8% males; 42.2% females). The deaths comprise 17.2% (191/1108) of all cancer deaths in 2010-2011 and 11.1% (461/4049) in 2012-2018 in the KUH catchment area (North-Savo Health Care District). In years 2012-2018, 14.1% of patients treated at KUH oncology clinic visited the palliative outpatient clinic. The percentage of DNR (do-not-resuscitate), palliative care, and end-of-life (EOL) care decisions increased significantly in the later period. The decisions were mainly made during the last week of life. The proportion of patients receiving chemotherapy during the last two weeks of life remained stable. CONCLUSION The proportion of patients receiving DNR, palliative care and EOL care decisions increased after the implementation of the palliative outpatient clinic, but the decisions were still made rather late, mainly during the last days of life.
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Affiliation(s)
- Anna-Maria Tolppanen
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Annamarja Lamminmäki
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Helena Länsimies
- University of Eastern Finland, Kuopio, Finland
- City of Kuopio, Kuopio, Finland
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Nieder C, Haukland EC, Mannsåker B. Shortened Palliative Radiotherapy Results in a Lower Rate of Treatment During the Last Month of Life. Cureus 2022; 14:e21617. [PMID: 35233303 PMCID: PMC8881233 DOI: 10.7759/cureus.21617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Palliative radiotherapy (PRT) during the last month of life (PRT30) should be avoided because relevant clinical benefits are unlikely to occur. While traditional short-course fractionation regimens are suitable for most patients, a minority may derive gains from higher doses of PRT. Compared to older regimens such as 13 fractions of 3 Gy, more hypofractionated, non-ablative concepts with reduced overall treatment time are not well studied. Methods Retrospective analysis (2017-2020) of 107 patients treated to metastatic lesions (one or two target volumes per patient) with traditional >2 weeks regimens or newer ≤2 weeks regimens, e.g. seven fractions of 5 Gy or five fractions of 6 Gy. Results Failure to complete radiotherapy was registered in 8% of patients (traditional fractionation) and 1%, respectively (p=0.12). Moderate rates of PRT30 were observed (11% and 6%, respectively, p=0.44). PRT30 was more likely in patients irradiated for brain or lymph node metastases. Utilization of newer ≤2 weeks regimens was highest in 2020, presumably as a result of the coronavirus disease 2019 (COVID-19) pandemic. Conclusion The implementation of newer fractionation regimens for selected patients has resulted in acceptable rates of non-completion and PRT30. Optimal selection criteria remain to be determined. Established, guideline-endorsed short-course regimens such as five fractions of 4 Gy and 8-Gy single fractions continue to represent important PRT approaches.
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Nieder C, Dalhaug A, Haukland E. The LabBM score is an excellent survival prediction tool in patients undergoing palliative radiotherapy. Rep Pract Oncol Radiother 2021; 26:740-746. [PMID: 34760308 DOI: 10.5603/rpor.a2021.0096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background and aim The prognostic assessment of patients referred for palliative radiotherapy can be conducted by site-specific scores. A quick assessment that would cover the whole spectrum could simplify the working day of clinicians who are not specialists for a particular disease site. This study evaluated a promising score, the LabBM (validated for brain metastases), in patients treated for other indications. Materials and methods The LabBM score was calculated in 375 patients by assigning 1 point each for C-reactive protein and lactate dehydrogenase above the upper limit of normal, and 0.5 points each for hemoglobin, platelets and albumin below the lower limit of normal. Uni- and multivariate analyses were performed. Results Median overall survival gradually decreased with increasing point sum (range 25.1-1.1 months). When grouped according to the original three-tiered model, excellent discrimination was found. Patients with 0-1 points had a median survival of 15.7 months. Those with 1.5-2 points had a median survival of 5.8 months. Finally, those with 2.5-3.5 points had a median survival of 3.2 months (all p-values ≤ 0.001). Conclusion The LabBM score, which is derived from inexpensive blood tests and easy to use, stratified patients into three very distinct prognostic groups and deserves further validation.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Astrid Dalhaug
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Ellinor Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
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Pobar I, Job M, Holt T, Hargrave C, Hickey B. Prognostic tools for survival prediction in advanced cancer patients: A systematic review. J Med Imaging Radiat Oncol 2021; 65:806-816. [PMID: 33973382 DOI: 10.1111/1754-9485.13185] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/31/2021] [Indexed: 12/23/2022]
Abstract
Survival prediction for palliative cancer patients by physicians is often optimistic. Patients with a very short life expectancy (<4 weeks) may not benefit from radiation therapy (RT), as the time to maximal symptom relief after treatment can take 4-6 weeks. We aimed to identify a prognostic tool (or tools) to predict survival of less than 4 weeks and less than 3 months in patients with advanced cancer to guide the choice of radiation dose and fractionation. We searched Embase, Medline (EBSCOhost) and CINAHL (EBSCOhost) clinical databases for literature published between January 2008 and June 2018. Seventeen studies met the inclusion criteria and were included in the review. Prediction accuracy at less than 4 weeks and less than 3 months were compared across the prognostic tools. Reporting of prediction accuracy among the different studies was not consistent: the Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI) and Number of Risk Factors (NRF) best-predicted survival duration of less than 4 weeks. The PPI, performance status with Palliative Prognostic Index (PS-PPI), NRF and Survival Prediction Score (SPS) may predict 3-month survival. We recommend PPI and PaP tools to assess the likelihood of a patient surviving less than 4 weeks. If predicted to survive longer and RT is justified, the NRF tool could be used to determine survival probability less than 3 months which can then help clinicians select dose and fractionation. Future research is needed to verify the reliability of survival prediction using these prognostic tools in a radiation oncology setting.
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Affiliation(s)
- Isaiah Pobar
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace, Brisbane, Queensland, Australia
| | - Mary Job
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace, Brisbane, Queensland, Australia
| | - Tanya Holt
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace, Brisbane, Queensland, Australia
| | - Catriona Hargrave
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace, Brisbane, Queensland, Australia.,QUT, Faculty of Health, School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Brigid Hickey
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace, Brisbane, Queensland, Australia
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Rautakorpi L, Jyrkkiö S, Löyttyniemi E, Hirvonen O. End-of-life care among patients with pancreatic cancer with or without palliative intervention: a retrospective single-centre study. Acta Oncol 2021; 60:106-111. [PMID: 32812832 DOI: 10.1080/0284186x.2020.1806356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Palliative care can reduce the symptom burden and may increase the life expectancy for patients with advanced malignancies. The aim of this study was to evaluate the impact of palliative intervention on the treatment procedures for pancreatic cancer patients during their last month of life. MATERIAL AND METHODS This retrospective single-centre study included adult pancreatic cancer patients who were treated in Turku University Hospital during their last month of life and died between 2011 and 2016. Data were collected from hospital database. Oncological treatments, the number of radiological examinations and procedures, surgical procedures, emergency department visits, hospitalisations, the place of death and medical costs were examined in tertiary care for patients with or without contact to the palliative care unit. RESULTS From 378 eligible patients, 20% (n = 76) had a contact to the palliative care unit. These patients had less radiological examinations (p < 0.0001), hospitalisations (p <0.0001) and emergency department visits (p = 0.021) during the last month of life. They did not die in the university hospital as often (p = 0.011) and median of their medical costs during the last month of life was approximately half (p <0.0001) when compared to patients with no palliative intervention (n = 302). They had longer overall survival (p <0.0001) which was the only difference detected in the characteristics of the groups. CONCLUSION Fewer treatment procedures and lower tertiary care costs during the last month of life were observed for the pancreatic cancer patients who had a contact to the palliative care unit. Palliative care intervention should be an essential part of the treatment schedule for these patients.
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Affiliation(s)
- Liisa Rautakorpi
- Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland
- Department of Clinical Oncology, University of Turku, Turku, Finland and
| | - Sirkku Jyrkkiö
- Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland
| | | | - Outi Hirvonen
- Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland
- Department of Clinical Oncology, University of Turku, Turku, Finland and
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Hirvonen OM, Leskelä RL, Grönholm L, Haltia O, Rissanen A, Tyynelä-Korhonen K, Rahko EK, Lehto JT, Saarto T. Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: a historic cohort study. Acta Oncol 2019; 58:1699-1705. [PMID: 31742490 DOI: 10.1080/0284186x.2019.1659512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life.Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013 - 31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N = 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC.Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33% ≤30 days before death, 18% with no decision). The median time from the decision to death was 46 days. Systemic cancer therapy was given during the last month of life in 1%, 36% and 38% (p < .001) and radiotherapy 22%, 40% and 31% (p = .03) cases, respectively; referral to a PC unit was made in 62%, 22% and 11%, respectively (p < .001). In logistic regression analyses younger age, shorter duration of the disease trajectory and type of cancer (e.g., breast cancer) were associated with a lack or late timing of the PC decision.Conclusion: The decision to initiate a palliative goal for the treatment was frequently made for cancer patients but occurred late for every third patient. Younger age and certain cancer types were associated with late PC decisions, thus leading to anti-cancer treatments continuing until close to the death with low access to a PC unit.
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Affiliation(s)
- Outi M. Hirvonen
- Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland
- Department of Clinical Oncology, University of Turku, Turku, Finland
| | | | - Lotta Grönholm
- Department of Palliative Care, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Olli Haltia
- Tuusula Health Care Centre, Tuusula, Finland
| | | | | | - Eeva K. Rahko
- Department of Clinical Oncology, Oulu University Hospital, Oulu, Finland
| | - Juho T. Lehto
- Department of Oncology, Palliative Care Unit, Tampere University Hospital and Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tiina Saarto
- Department of Palliative Care, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
- Department of Palliative Care, Comprehensive Cancer Center, University of Helsinki, Helsinki, Finland
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Palliative thoracic radiotherapy near the end of life in lung cancer: A population-based analysis. Lung Cancer 2019; 135:97-103. [PMID: 31447009 DOI: 10.1016/j.lungcan.2019.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Palliative thoracic radiotherapy (RT) can improve quality of life for patients with advanced lung cancer, but treatment can be associated with acute toxicity and symptomatic relief may take several weeks. The optimal fractionation schedule is not known. Delivery of RT near the end of life (EOL) is an emerging indicator of poor quality care. The aim of this study was to determine utilization of palliative thoracic RT in the last 4 weeks of life, and factors associated with its use, in patients with incurable lung cancer in a population-based healthcare system. MATERIALS AND METHODS All patients with lung cancer in British Columbia treated with palliative thoracic RT in 2014 and 2015 were identified. Associations between starting a course of palliative thoracic RT within 4 weeks of death and patient/treatment characteristics were assessed using univariate and multivariate logistic regression analysis. RESULTS 1676 courses of palliative thoracic RT were delivered to 1584 lung cancer patients. Median survival was 20 weeks. 12% of palliative thoracic RT courses were delivered in the last 4 weeks of life, with short fractionation schedules and simple RT planning techniques used more frequently near EOL. Of RT courses delivered in the last 4 weeks of life 89% were courses of 1 - 5 fractions, 75% were completed as prescribed and 94% involved simple 1-2 field RT techniques. Receipt of RT in the last 4 weeks of life was associated with male gender, younger age, poor performance status, metastatic disease, small cell carcinoma histology and no prior chemotherapy. CONCLUSION Further study and standardization of quality indicators for palliative RT utilization near EOL is required. Whilst clarification occurs, physicians should consider the prognosis of patients with incurable lung cancer and the realistic expectation of benefit from palliative thoracic RT when considering treatment indications and fractionation schedules.
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