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Chamberlain C, Tammes P, Jones T, Pullyblank A, Blazeby JM, Thackray KE, McPhail S, McNair AGK. 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. J Clin Epidemiol 2023; 163:51-61. [PMID: 37659581 DOI: 10.1016/j.jclinepi.2023.08.018] [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: 03/16/2023] [Revised: 07/25/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
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.
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Affiliation(s)
- Charlotte Chamberlain
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK; Specialised Services, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Peter Tammes
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK; National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE
| | - Timothy Jones
- Specialised Services, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK; National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Anne Pullyblank
- Department of Gastrointestinal Surgery, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK; Division of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Katherine E Thackray
- National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE
| | - Sean McPhail
- National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE
| | - Angus G K McNair
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK; Department of Gastrointestinal Surgery, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK.
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Hsu PK, Chen HS, Liu CC, Wu SC. Neoadjuvant Chemoradiation Versus Upfront Esophagectomy in Clinical Stage II and III Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2018; 26:506-513. [PMID: 30430325 DOI: 10.1245/s10434-018-7060-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Hui-Shan Chen
- Department of Health Care Administration, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Chia-Chuan Liu
- Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Shiao-Chi Wu
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
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Merchant SJ, Brogly SB, Goldie C, Booth CM, Nanji S, Patel SV, Lajkosz K, Baxter NN. Palliative Care is Associated with Reduced Aggressive End-of-Life Care in Patients with Gastrointestinal Cancer. Ann Surg Oncol 2018; 25:1478-1487. [DOI: 10.1245/s10434-018-6430-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Indexed: 12/25/2022]
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Chen HS, Hsu PK, Liu CC, Wu SC. Upfront surgery and pathological stage-based adjuvant chemoradiation strategy in locally advanced esophageal squamous cell carcinoma. Sci Rep 2018; 8:2180. [PMID: 29391589 PMCID: PMC5794775 DOI: 10.1038/s41598-018-20654-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 01/22/2018] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Hui-Shan Chen
- Department of Health Care Administration, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Chia-Chuan Liu
- Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Shiao-Chi Wu
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
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Merchant SJ, Lajkosz K, Brogly SB, Booth CM, Nanji S, Patel SV, Baxter NN. The Final 30 Days of Life. J Palliat Care 2017; 32:92-100. [DOI: 10.1177/0825859717738464] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
| | - Katherine Lajkosz
- Institute for Clinical Evaluative Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Susan B. Brogly
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Sunil V. Patel
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Nancy N. Baxter
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
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