Hospital cancer deaths: late diagnosis and missed opportunity

Age and cancer type: associations with increased odds of receiving a late diagnosis in people with advanced cancer

PURPOSE

In order to deliver appropriate and timely care planning and minimise avoidable late diagnoses, clinicians need to be aware of which patients are at higher risk of receiving a late cancer diagnosis. We aimed to determine which demographic and clinical factors are associated with receiving a 'late' cancer diagnosis (within the last 12 weeks of life).

METHOD

Retrospective cohort study of 2,443 people who died from cancer ('cancer decedents') in 2013-2015. Demographic and cancer registry datasets linked using patient-identifying Community Health Index numbers. Analysis used binary logistic regression, with univariate and adjusted odds ratios (SPSS v25).

RESULTS

One third (n = 831,34.0%) received a late diagnosis. Age and cancer type were significantly associated with late cancer diagnosis (p < 0.001). Other demographic factors were not associated with receiving a late diagnosis. Cancer decedents with lung cancer (Odds Ratios presented in abstract are the inverse of those presented in the main text, where lung cancer is the reference category. Presented as 1/(OR multivariate)) were more likely to have late diagnosis than those with bowel (95% Confidence Interval [95%CI] Odds Ratio (OR)1.52 (OR1.12 to 2.04)), breast or ovarian (95%CI OR3.33 (OR2.27 to 5.0) or prostate (95%CI OR9.09 (OR4.0 to 20.0)) cancers. Cancer decedents aged > 85 years had higher odds of late diagnosis (95%CI OR3.45 (OR2.63 to 4.55)), compared to those aged < 65 years.

CONCLUSIONS

Cancer decedents who were older and those with lung cancer were significantly more likely to receive late cancer diagnoses than those who were younger or who had other cancer types.

Hospitalisations of patients with cancer in the last stage of life. Reason to improve advance care planning?

OBJECTIVE

The aim of this study is to examine why patients are hospitalised in the last stage of life.

METHODS

Our study was conducted in a large Dutch teaching hospital. We conducted a retrospective chart review of patients aged ≥18 years who died of cancer either during hospitalisation or after discharge to receive terminal care outside the hospital. We collected data about the characteristics of these hospitalisations and indicators of advance care planning.

RESULTS

Of the 264 deceased patients, 56% had died in the hospital and 44% after hospital discharge. Of all patients, 80% had been admitted to the hospital because of symptom distress. Dyspnoea (39%) and pain (33%) were the most common symptoms. Most patients underwent diagnostic procedures (laboratory tests [97%] and radiology tests [91%]) and received medical treatment (analgesics [71%] and antibiotics [55%]) during their hospitalisation. A 'Do-Not-Resuscitate' code had been recorded before admission in 42% of the patients and in an additional 52% during admission.

CONCLUSION

Our study shows that patients with cancer in the last stage of life were mainly admitted to the hospital because of symptom distress. Some hospitalisations and in-hospitals deaths may be avoided by more timely recognition of patients' impending death and start of advance care planning.

Preferred Place of Death in Adult Cancer Patients: A Systematic Review and Meta-Analysis

Background: Identifying the preferred place of death is a key indicator of the quality of death in cancer patients and one of the most important issues for health service policymakers. This study was done to determine the preferred place of death and the factors affecting it for adult patients with cancer.

Methods: In this systematic review and meta-analysis study four online databases (PubMed, Scopus, web of science, ProQuest) were searched by relevant keywords. Quality assessment of papers was conducted using Newcastle-Ottawa (NOS) criterion. Odds ratios, relative risks, and 95% confidence intervals were determined for each of the factors extracted from the investigations.

Results: A total of 14,920 participants of 27 studies were included into the meta-analysis. Based on the results, 55% of cancer patients with a confidence interval [95% CI (41–49)] preferred home, 17% of patients with a confidence interval [95% CI (−12%) 23)] preferred hospital and 10% of patients with confidence interval [95% CI (13–18)] preferred hospices as their favored place to die. Effective factors were also reported in the form of demographic characteristics, disease-related factors and psychosocial factors.

Conclusions: This study showed that more than half of cancer patients chose home as their preferred place of death. Therefore, guided policies need to ensure that the death of the patients in the preferred place should be considered with priority.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020218680, identifier: CRD42020218680.

Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis

BACKGROUND

Out-of-hours (OOH) hospital admissions for patients receiving end-of-life care are a common cause of concern for patients, families, clinicians, and policymakers. It is unclear what issues, or combinations of issues, lead OOH clinicians to initiate hospital care for these patients.

AIM

To investigate the circumstances, processes, and mechanisms of UK OOH services-initiated end-of-life care hospital admissions.

DESIGN AND SETTING

Systematic literature review and narrative synthesis.

METHOD

Eight electronic databases were searched from inception to December 2019 supplemented by hand-searching of the British Journal of General Practice. Key search terms included: 'out-of-hours services', 'hospital admissions', and 'end-of-life care'. Two reviewers independently screened and selected articles, and undertook quality appraisal using Gough's Weight of Evidence framework. Data was analysed using narrative synthesis and reported following PRISMA Complex Intervention guidance.

RESULTS

Searches identified 20 727 unique citations, 25 of which met the inclusion criteria. Few studies had a primary focus on the review questions. Admissions were instigated primarily to address clinical needs, caregiver and/or patient distress, and discontinuity or unavailability of care provision, and they were arranged by a range of OOH providers. Reported frequencies of patients receiving end-of-life care being admitted to hospital varied greatly; most evidence related to cancer patients.

CONCLUSION

Although OOH end-of-life care can often be readily resolved by hospital admissions, it comes with multiple challenges that seem to be widespread and systemic. Further research is therefore necessary to understand the complexities of OOH services-initiated end-of-life care hospital admissions and how the challenges underpinning such admissions might best be addressed.

Discordance between the perceptions of clinicians and families about end-of-life trajectories in hospitalized dementia patients

BACKGROUND

Due to the unpredictable dementia trajectory, it is challenging to recognize illness progression and the appropriateness of a palliative approach. Further confusion occurs during hospitalization where the presence of comorbid conditions complicates prognostication. This research examined clinicians and families' perceptions of dementia as a terminal condition in relation to end-of-life admissions.

CONTEXT

The study was based in the General Medicine units of one Australian public hospital. Medical, nursing, and social work clinicians were recruited to reflect multidisciplinary perspectives. Bereaved caregivers of deceased patients with dementia were interviewed 3 months following death.

METHODS

Qualitative research underpinned by a social constructionist epistemology and framed through complex systems theory. Semi-structured interviews generated data that illuminated perceptions of deterioration observed toward the end of life.

RESULTS

Although participants anticipated general cognitive and physical deterioration associated with dementia, the emergence of comorbid illness made it difficult to predict the onset of the end of life. During a hospital admission, clinicians attributed the end of life to the advanced outcomes of dementia, whereas families described new medical crises. End-of-life admissions illuminated intersections between dementia and comorbidities rather than illness progression. In contrast with the perception that people with dementia lose awareness at the end of life, families drew attention to evidence that their loved one was present during the dying phase.

SIGNIFICANCE OF RESULTS

Our findings challenge the dominant understanding of dementia trajectories. Bifurcations between clinicians and families' views demonstrate the difficulties in recognizing end-of-life transitions. Implications for the integration of palliative care are considered.

Mass spectrometry-based iTRAQ analysis of serum markers in patients with pancreatic cancer

Early biomarkers for pancreatic cancer (PC) detection are required in order to improve patient outcomes. The present study aimed to identify serum biomarkers for PC diagnosis using proteomics, unveil the underlying pathological mechanisms and provide reliable data for the early diagnosis of PC. Isobaric tags for relative and absolute quantification and two-dimensional-liquid chromatography-tandem mass spectometry were used to compare serum samples from patients with PC and healthy individuals. Mascot and Scaffold were used for raw data processing, and Panther for gene ontology (GO) analysis. Igenuity^® Pathway Analysis (IPA) was utilized to assess canonical pathways and protein-protein interactions. In total, 76 differentially expressed proteins were identified. The candidate protein DNA repair protein 50 (RAD50) was elevated in patients with PC compared with healthy individuals. In addition, transforming growth factor-β1 (TGF-β1) and apoptotic protease activating factor 1 (APAF-1) were downregulated in PC. GO analysis revealed that the extracellular matrix was increased in PC, as well as receptor function and enzyme regulation; additionally, reduced nucleic acid binding transcription factor activity was observed. IPA analysis demonstrated that the significantly altered canonic pathways were liver X receptor/retinoid X receptor (RXR) activation, the production of nitric oxide and reactive oxygen species in macrophages, the coagulation system, acute phase response signaling and lipopolysaccharide/interleukin-1 mediated inhibition of RXR function. To conclude, RAD50, TGF-β1 and APAF1 are candidate biomarkers for the diagnosis of early PC. The results from the present study could help identify future therapeutic drugs for PC.

Carbon Nanotube Matrix for Highly Sensitive Biosensors To Detect Pancreatic Cancer Biomarker CA19-9

Biosensors fabricated with nanomaterials promise faster, cheaper, and more efficient alternatives to traditional, often bulky devices for early cancer diagnosis. In this study, we fabricated a thin film sensing unit on interdigitated gold electrodes combining polyethyleneimine and carbon nanotubes in a layer by layer fashion, onto which antibodies anti-CA19-9 were adsorbed with a supporting layer of N-hydroxysuccinimide and 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide solution. By use of impedance spectroscopy, the pancreatic cancer biomarker CA19-9 was detected in a buffer with limit of detection of 0.35 U/mL. This high sensitivity allowed for distinction between samples of blood serum from patients with distinct probabilities to develop pancreatic cancer. The selectivity of the biosensor was confirmed in subsidiary experiments with HT-29 and SW-620 cell lines and possible interferents, e.g., p53 protein, ascorbic acid, and glucose, where significant changes in capacitance could only be measured with HT-29 that contained the CA19-9 biomarker. Chemisorption of CA19-9 molecules onto the layer of anti-CA19-9 antibodies was the mechanism responsible for sensing while electrostatic interactions drove the adsorption of carbon nanotubes, according to polarization-modulated infrared reflection absorption spectroscopy (PM-IRRAS). The adsorption behavior was successfully described by the Langmuir-Freundlich isotherm.