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Mah SJ, Seow H, Schnarr K, Reade CJ, Gayowsky A, Chan KKW, Sinnarajah A. Trends in quality indicators of end-of-life care for women with gynecologic malignancies in Ontario, Canada. Gynecol Oncol 2022; 167:247-255. [PMID: 36163056 DOI: 10.1016/j.ygyno.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/18/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A large body of research has validated several quality indicators of end-of-life (EOL) cancer care, but few have examined these in gynecologic cancer at a population-level. We examined patterns of EOL care quality in patients with gynecologic cancers across 13 years in Ontario, Canada. METHODS We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care databases. Proportions of quality indices were calculated, including: emergency department (ED) use, hospital or intensive care unit (ICU) admission, chemotherapy ≤14 days of death, cancer-related surgery, tube or intravenous feeds, palliative home visits, and hospital death. We used multivariable logistic regression to examine factors associated with receipt of aggressive and supportive care. RESULTS There were 16,237 included decedents over the study period; hospital death rates decreased from 47% to 37%, supportive care use rose from 65% to 74%, and aggressive care remained stable (16%). Within 30 days of death, 50% were hospitalized, 5% admitted to ICU, and 67% accessed palliative homecare. Within 14 days of death, 31% visited the ED and 4% received chemotherapy. Patients with vulvovaginal cancers received the lowest rates of aggressive and supportive care. Using multivariable analyses, factors associated with increased aggressive EOL care use included younger age, shorter disease duration, lower income quintiles, and rural residence. CONCLUSIONS Over time, less women dying with gynecologic cancers in Ontario experienced death in hospital, and more accessed supportive care. However, the majority were still hospitalized and a significant proportion received aggressive care in the final 30 days of life.
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Affiliation(s)
- Sarah J Mah
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, McMaster University, Hamilton, Canada.
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Kara Schnarr
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Clare J Reade
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, McMaster University, Hamilton, Canada
| | | | - Kelvin K W Chan
- Department of Oncology, University of Toronto, Toronto, Canada
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Bjørnelv G, Hagen TP, Forma L, Aas E. Care pathways at end-of-life for cancer decedents: registry based analyses of the living situation, healthcare utilization and costs for all cancer decedents in Norway in 2009-2013 during their last 6 months of life. BMC Health Serv Res 2022; 22:1221. [PMID: 36183057 PMCID: PMC9526273 DOI: 10.1186/s12913-022-08526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/29/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Research on end-of-life care is often fragmented, focusing on one level of healthcare or on a particular patient subgroup. Our aim was to describe the complete care pathways of all cancer decedents in Norway during the last six months of life. METHODS We used six national registries linked at patient level and including all cancer decedents in Norway between 2009-2013 to describe patient use of secondary, primary-, and home- and community-based care. We described patient's car pathway, including patients living situation, healthcare utilization, and costs. We then estimated how cancer type, individual and sociodemographic characteristics, and access to informal care influenced the care pathways. Regression models were used depending on the outcome, i.e., negative binomial (for healthcare utilization) and generalized linear models (for healthcare costs). RESULTS In total, 52,926 patients were included who died of lung (16%), colorectal (12%), prostate (9%), breast (6%), cervical (1%) or other (56%) cancers. On average, patients spent 123 days at home, 24 days in hospital, 16 days in short-term care and 24 days in long-term care during their last 6 months of life. Healthcare utilization increased towards end-of-life. Total costs were high (on average, NOK 379,801). 60% of the total costs were in the secondary care setting, 3% in the primary care setting, and 37% in the home- and community-based care setting. Age (total cost-range NOK 361,363-418,618) and marital status (total cost-range NOK354,100-411,047) were stronger determining factors of care pathway than cancer type (total cost-range NOK341,318- 392,655). When patients died of cancer types requiring higher amounts of secondary care (e.g., cervical cancer), there was a corresponding lower utilization of primary, and home- and community-based care, and vice versa. CONCLUSION Cancer patient's care pathways at end-of-life are more strongly associated with age and access to informal care than underlying type of cancer. More care in one care setting (e.g., the secondary care) is associated with less care in other settings (primary- and home- and community based care setting) as demonstrated by the substitution between the different levels of care in this study. Care at end-of-life should therefore not be evaluated in one healthcare level alone since this might bias results and lead to suboptimal priorities.
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Affiliation(s)
- Gudrun Bjørnelv
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje P. Hagen
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Leena Forma
- grid.502801.e0000 0001 2314 6254Faculty of Social Sciences, Tampere University, Tampere, Finland ,grid.436211.30000 0004 0400 1203Laurea University of Applied Sciences, Vantaa, Finland
| | - Eline Aas
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,Division for Health Services, Institute of Public Health, Oslo, Norway
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End-of-life care for patients with advanced ovarian cancer in the Netherlands: A retrospective registry-based analysis. Gynecol Oncol 2022; 166:148-153. [DOI: 10.1016/j.ygyno.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/19/2022]
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Kanter K, Fish M, Mauri G, Horick NK, Allen JN, Blaszkowsky LS, Clark JW, Ryan DP, Nipp RD, Giantonio BJ, Goyal L, Dubois J, Murphy JE, Franses J, Klempner SJ, Roeland EJ, Weekes CD, Wo JY, Hong TS, Van Seventer EE, Corcoran RB, Parikh AR. Care Patterns and Overall Survival in Patients With Early-Onset Metastatic Colorectal Cancer. JCO Oncol Pract 2021; 17:e1846-e1855. [PMID: 34043449 DOI: 10.1200/op.20.01010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Colorectal cancer (CRC) incidence in patients younger than 50 years of age, commonly defined as early-onset (EO-CRC), is rising. EO-CRC often presents with distinct clinicopathologic features. However, data on prognosis are conflicting and outcomes with modern treatment approaches for metastatic disease are still limited. MATERIALS AND METHODS We prospectively enrolled patients with metastatic CRC (mCRC) to a biobanking and clinical data collection protocol from 2014 to 2018. We grouped the cohort based on age at initial diagnosis: < 40 years, 40-49 years, and ≥ 50 years. We used regression models to examine associations among age at initial diagnosis, treatments, clinicopathologic features, and survival. RESULTS We identified 466 patients with mCRC (45 [10%] age < 40 years, 109 [23%] age 40-49 years, and 312 [67%] age ≥ 50 years). Patients < 40 years of age were more likely to have received multiple metastatic resections (odds ratio [OR], 3.533; P = .0066) than their older counterparts. Patients with EO-CRC were more likely to receive triplet therapy than patients > 50 years of age (age < 40 years: OR, 6.738; P = .0002; age 40-49 years: OR, 2.949; P = .0166). Patients 40-49 years of age were more likely to have received anti-EGFR therapy (OR, 2.633; P = .0016). Despite differences in care patterns, age did not predict overall survival. CONCLUSION Despite patients with EO-CRC receiving more intensive treatments, survival was similar to the older counterpart. However, EO-CRC had clinical and molecular features associated with worse prognoses. Improved biologic understanding is needed to optimize clinical management of EO-CRC. The cost-benefit ratio of exposing patients with EO-CRC to more intensive treatments has to be carefully evaluated.
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Affiliation(s)
- Katie Kanter
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Madeleine Fish
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Gianluca Mauri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA.,Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Dipartimento di Oncologia e Emato-Oncologia, Università degli Studi di Milano (La Statale), Milan, Italy
| | - Nora K Horick
- Department of Statistics, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Jill N Allen
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - David P Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Bruce J Giantonio
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Lipika Goyal
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jon Dubois
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Janet E Murphy
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Joseph Franses
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Samuel J Klempner
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Eric J Roeland
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Colin D Weekes
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Emily E Van Seventer
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Ryan B Corcoran
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Aparna R Parikh
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
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Nica A, Lee JYJ, Hong NL, May T. Cost-effectiveness of maintenance hormonal therapy in patients with advanced low grade serous ovarian cancer. Gynecol Oncol 2020; 160:206-213. [PMID: 33032821 DOI: 10.1016/j.ygyno.2020.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/28/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness of using maintenance hormonal therapy in patients with low grade serous ovarian cancer (LGSC). METHODS A simulated decision analysis with a Markov decision model over a lifetime horizon was performed using the base case of a 47-year old patient with stage IIIC, LGSC following first-line treatment with primary cytoreductive surgery and adjuvant chemotherapy. Two treatment strategies were analyzed - maintenance daily letrozole until disease progression and routine observation. The analysis was from the perspective of the healthcare payer. Direct medical costs were estimated using public data sources and previous literature and were reported in adjusted 2018 Canadian dollars. The model estimated lifetime cost, quality-adjusted life years (QALY), life years (LY), median overall survival (OS), and number of recurrences with each strategy. Cost-effectiveness was compared using an incremental cost-effectiveness ratio (ICER). A strategy was considered cost-effective when the ICER was less than the willingness to pay (WTP) threshold of $50,000 CAD per QALY. Deterministic sensitivity analysis was performed to assess the impact of changing key clinical and cost variables. RESULTS Maintenance letrozole was the preferred strategy with an associated lifetime cost of $69,985 CAD ($52,620 USD) and an observed improvement of 0.91 QALYs and 1.55 LYs. The ICER for letrozole maintenance therapy was an additional $11,037 CAD ($8298 USD) per QALY. The modeled median OS was 150 months with maintenance letrozole and 126 months in the observation strategy. The maintenance letrozole strategy resulted in 34% and 17% fewer first recurrences at 5-year and 10-year follow-up, respectively. CONCLUSION Maintenance letrozole is a cost-effective treatment strategy in patients with advanced LGSC resulting in clinically-relevant improvement in QALYs, LYs, and fewer disease recurrences.
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Affiliation(s)
- Andra Nica
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, ON, Canada
| | | | - Nicole Look Hong
- Department of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Taymaa May
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Department of Surgical Oncology, Princess Margaret Cancer Center, Toronto, ON, Canada.
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Sompratthana T, Phoolcharoen N, Schmeler KM, Lertkhachonsuk R. End-of-life symptoms and interventions among women with gynecologic cancers in a tertiary-care hospital in Thailand. Int J Gynecol Cancer 2019; 29:ijgc-2019-000338. [PMID: 31079059 DOI: 10.1136/ijgc-2019-000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Studies have shown improved patient quality of life with supportive care rather than aggressive treatment at the end of life. This study evaluated the symptoms that patients in Thailand with gynecologic cancers experienced and the interventions that they received at the end of life. METHODS The medical records of patients admitted to a tertiary cancer center in Thailand who died in the hospital from gynecologic malignancies between January 1, 2011 and December 31, 2016 were reviewed. Inclusion criteria were patients who had been been diagnosed with gynecologic cancers (ovarian, endometrial, cervical, vulvar, or peritoneal cancers or uterine sarcomas) and had died in the hospital during that period. Patients whose medical records were incomplete or unavailable were excluded from the study. Data on demographics, symptoms, interventions, and end-of-life care were collected. RESULTS A total of 159 patients were included in this analysis. The mean age at death was 54.3 (range 15-91) years. Over half (54.7%) of the patients were diagnosed with ovarian or peritoneal cancer, 26.4% with uterine cancer or sarcoma, 16.4% with cervical cancer, and 1.3% with dual primary cancers. Symptoms at time of admission were poor oral intake (68.6%), abdominal distention or discomfort (63.5%), pain (42.8%), nausea or vomiting (35.2%), and fever or signs of infection (27.0%). The mean number of hospitalizations during the last 6 months was 3.6. Thirty-six patients (22.6%) had major surgery during the last 6 months of life, with 14 patients (8.8%) having it performed during their last admission before death. The mean length of the last hospital stay was 22.3 (range 6-31) days, and 61 patients (38.4%) were admitted to the intensive care unit. Eleven patients (6.9%) had chemotherapy in their last 14 days of life and 10 (6.3%) received cardiopulmonary resuscitation. Almost all patients (153, 96.2%) had do-not-resuscitate (DNR) consents. The mean time between the DNR consent and death was 6.3±9.7 days. CONCLUSION Multiple hospital admissions, aggressive treatments, and invasive procedures were common among patients with gynecologic cancer at the end of life. Better symptom management, end-of-life preparation, and communication are needed to enhance patients' quality of life in Thailand.
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Affiliation(s)
- Thanchanok Sompratthana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natacha Phoolcharoen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ruangsak Lertkhachonsuk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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