Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients’ Last Month of Life, 2001–2010

Novel methods to define invasive procedures at the end of life were developed to improve quality of end of life care research: a population-based cohort study in colorectal cancer

BACKGROUND

Understanding the use of invasive procedures (IPs) at the end of life (EoL) is important to avoid undertreatment and overtreatment, but epidemiologic analysis is hampered by limited methods to define treatment intent and EoL phase. This study applied novel methods to report IPs at the EoL using a colorectal cancer case study.

METHODS

An English population-based cohort of adult patients diagnosed between 2013 and 2015 was used with follow-up to 2018. Procedure intent (curative, noncurative, diagnostic) by cancer site and stage at diagnosis was classified by two surgeons independently. Joinpoint regression modeled weekly rates of IPs for 36 subcohorts of patients with incremental survival of 0-36 months. EoL phase was defined by a significant IP rate change before death. Zero-inflated Poisson regression explored associations between IP rates and clinical/sociodemographic variables.

RESULTS

Of 87,731 patients included, 41,972 (48%) died. Nine thousand four hundred ninety two procedures were classified by intent (inter-rater agreement 99.8%). Patients received 502,895 IPs (1.39 and 3.36 per person year for survivors and decedents). Joinpoint regression identified significant increases in IPs 4 weeks before death in those living 3-6 months and 8 weeks before death in those living 7-36 months from diagnosis. Seven thousand nine hundred eight (18.8%) patients underwent IPs at the EoL, with stoma formation the most common major procedure. Younger age, early-stage disease, men, lower comorbidity, those receiving chemotherapy, and living longer from diagnosis were associated with IPs.

CONCLUSION

Methods to identify and classify IPs at the EoL were developed and tested within a colorectal cancer population. This approach can be now extended and validated to identify potential undertreatment and overtreatment.

Neoadjuvant Chemoradiation Versus Upfront Esophagectomy in Clinical Stage II and III Esophageal Squamous Cell Carcinoma

BACKGROUND

The benefits of neoadjuvant chemoradiation (NCRT) compared to upfront esophagectomy (UE) in esophageal squamous cell carcinoma (ESCC) is controversial. Our purpose was to determine whether clinical stages based on the 8th edition American Joint Committee on Cancer Tumor-Node-Metastasis staging system could guide treatment decision.

METHODS

Data from 2503 patients with clinical stages II and III ESCC diagnosed between 2008 and 2014 were obtained from a nationwide database. Propensity score matching was used to identify well-balanced pairs of patients. Cox proportional hazards regression and log-rank test were used in the survival analysis. The outcomes of patients receiving "NCRT followed by surgery" or "UE" strategies were compared.

RESULTS

The treatment modality (UE or NCRT) was not a prognostic factor in clinical stage II ESCC (HR: 0.97; p = 0.778). In contrast, the UE group demonstrated a significantly worse outcome compared with the NCRT group in clinical stage III ESCC (HR: 1.39; p < 0.001). After matching, patients who underwent UE for clinical stage II ESCC had median survival/3-year overall survival (OS) rates of 27.8 months/39.2% compared with 32.7 months/49.8% in the NCRT group (p = 0.508). The patients who underwent UE for clinical stage III ESCC had median survival/3-year OS rates of 17.9 months/28.2% in the UE group compared with 24.0 months/41.8% in the NCRT group (p < 0.001).

CONCLUSIONS

Our data suggest that NCRT strategy improved survival compared with UE in clinical stage III ESCC but not in clinical stage II tumors.

Upfront surgery and pathological stage-based adjuvant chemoradiation strategy in locally advanced esophageal squamous cell carcinoma

Adjuvant chemoradiation is reported to have a survival benefit for esophageal squamous cell carcinoma (ESCC). We evaluated the “upfront surgery and pathological stage-based adjuvant chemoradiation” strategy, in which adjuvant therapy is guided by pathological stage, in locally advanced ESCC. Data from 2976 clinical stage II/III ESCC patients, including 1735 in neoadjuvant chemoradiation and 1241 in upfront surgery groups, were obtained from a nationwide database. Patients in the upfront surgery group were further categorized into the “upfront surgery and pathological stage-based adjuvant chemoradiation” and “upfront surgery only” groups. The 3-year overall survival (OS) rates in the “neoadjuvant chemoradiation”, “upfront surgery and pathological stage-based adjuvant chemoradiation”, and “upfront surgery only” groups were 41.5%, 45.8%, and 28.5%, respectively. In propensity score matched patients, the 3-year OS rate was 41.7% in the neoadjuvant chemoradiation group, compared to 35.6% in the “upfront surgery and pathological stage-based adjuvant chemoradiation” group (p = 0.147), and 20.3% in the “upfront surgery only” group (p < 0.001). No survival difference was observed between the “neoadjuvant chemoradiation followed by surgery” protocol and the “upfront surgery and pathological stage-based adjuvant chemoradiation” strategy.

The Final 30 Days of Life

Background:

Studies have reported overly aggressive end-of-life care (EOLC) in many cancers. We investigate trends in, and factors associated with, aggressive EOLC among patients who died of gastrointestinal (GI) cancers in Ontario, Canada.

Methods:

All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified through the Ontario Cancer Registry, and information was collected from linked databases. Outcomes representing aggressive EOLC were assessed: administration of chemotherapy, any emergency department (ED) visits, hospital admissions, intensive care unit (ICU) admissions (all within 30 days of death), death in hospital and in ICU, and a composite outcome representing any aggressive EOLC. Temporal trends were analyzed using the Cochran-Armitage test.

Results:

There were 34 630 patients in the cohort: 43% colon, 26% anorectal, 19% gastric, and 12% esophageal cancers. Aggressive EOLC was delivered to 65%, with a significantly decreasing trend from 64.8% in 2003 to 62.5% in 2013 ( P = .001). Utilization of specific elements of aggressive EOLC included 8% chemotherapy, 46% ED visits, 49% hospital admissions, 6% ICU admissions, 45% death in hospital, and 5% death in ICU. Trends over the study period showed that ED visits (from 43% to 46.9%; P = .0001) and death in ICU (from 3.7% to 4.9%; P = .04) significantly increased; hospital admissions (from 48.9% to 47.8%; P = .02) and death in hospital (from 46.6% to 38.9%; P < .0001) significantly decreased.

Conclusions:

Two-thirds of patients with GI cancer had aggressive EOLC in the last 30 days of life.