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Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer.

ABSTRACT: PURPOSE:End-of-life (EOL) chemotherapy has been described as the most widespread, wasteful, and unnecessary practice in oncology, with benchmarking aimed to reduce physician use of chemotherapy within 14 days of EOL. We evaluated the recent transformation of EOL chemotherapy and targeted therapy practices nationally. METHODS:In patients older than 65 years of age who died as a result of breast (n = 19,887), lung (n = 79,613), colorectal (n = 29,844), or prostate (n = 17,910) cancer between 2007 and 2013, we evaluated the guideline-benchmarked measure of chemotherapy use within 14 days of EOL in SEER-Medicare. Comparison outcomes were nonbenchmarked measures of chemotherapy and targeted therapy across time points within 6 months of EOL. Cochran-Armitage test was used to evaluate temporal trends. Multilevel logistic models and intraclass correlation coefficient was used to evaluate variation in EOL chemotherapy use at the physician level. RESULTS:From 2007 to 2013, chemotherapy within 14 days of EOL declined from 6.7% to 4.9% of patients (Ptrend < .001; ? = -1.8%). Similar declines occurred for chemotherapy within 1 month (Ptrend < .001; ? = -1.8%) and 2 months (Ptrend < .001; ? = -1.3%) of EOL. In contrast, chemotherapy within 4 to 6 months of EOL rose (Ptrend ? .04; ? = 0.7% to 1.7%), and 43.0% of all patients received chemotherapy within 6 months of EOL. Frequency of targeted therapy use across all time points within 6 months of EOL was stable to marginally rising from 2007 to 2013 (Ptrend = .09 to .82; ? = -0.2% to 1.8%); overall, 1.2% received targeted therapy within 14 days and 3.6% within 1 month of EOL. By 2013, 13.2% of patients received any targeted therapy within 6 months of EOL. In a multilevel model, 5.19% (intraclass correlation coefficient) of variation in 14-day EOL chemotherapy was attributed to the physician level. CONCLUSION:With national benchmarking, chemotherapy within 14 days of EOL successfully declined to less than 5%, with comprehensive benchmark uptake by physicians. Results may inform current strategies to help to achieve high-value EOL oncology practice.

SUBMITTER: Fang P

PROVIDER: S-EPMC6638601 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer.

Fang Penny P Jagsi Reshma R He Weiguo W Lei Xiudong X Campbell Eric G EG Giordano Sharon H SH Smith Grace L GL

Journal of clinical oncology : official journal of the American Society of Clinical Oncology 20190529 20

<h4>Purpose</h4>End-of-life (EOL) chemotherapy has been described as the most widespread, wasteful, and unnecessary practice in oncology, with benchmarking aimed to reduce physician use of chemotherapy within 14 days of EOL. We evaluated the recent transformation of EOL chemotherapy and targeted therapy practices nationally.<h4>Methods</h4>In patients older than 65 years of age who died as a result of breast (n = 19,887), lung (n = 79,613), colorectal (n = 29,844), or prostate (n = 17,910) cance ...[more]

PMID: 31141431

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Project description:IntroductionThere are increasing concerns about the negative impacts of chemotherapy near the end of life (EOL). There is discrepancy among different countries about its use, and little is known about the real-world situation in China.Patients and methodsThis retrospective study was conducted at six representative hospitals across China. Adult decedents with a record of advanced solid cancer and palliative chemotherapy were consecutively screened from 2010 through 2014. The prevalence of EOL chemotherapy within the last 1 month of life was set as the primary outcome. The correlations among EOL chemotherapy, clinicopathological features, and overall survival (OS) were investigated.ResultsA total of 3,350 decedents who had had cancer were consecutively included; 2,098 (62.6%) were male and the median age was 56 years (range, 20-88). There were 177 (5.3%), 387 (11.6%), and 837 (25.0%) patients who received EOL chemotherapy within the last 2 weeks, 1 month, and 2 months of life, respectively. We identified inferior OS (median OS, 7.1 vs. 14.2 months; hazard ratio, 1.37; 95% confidence interval [CI], 1.23-1.53; p < .001), more intensive treatments (e.g., admitted to intensive care unit [ICU] in the last month of life, received cardiopulmonary resuscitation and invasive ventilation support), and hospital death (odds ratio, 1.53; 95% CI, 1.14-2.06; p?=?.005) among patients who received continued chemotherapy within the last month compared with those who did not. However, subgroup analyses indicated that receiving oral agents correlated with fewer ICU admissions and lower rates of in-hospital death.ConclusionThis study showed that EOL chemotherapy is commonly used in China. Intravenous chemotherapy at the EOL significantly correlated with poor outcomes and the role of oral anticancer agents warrants further investigation. The Oncologist 2017;22:53-60Implications for Practice: The role of chemotherapy toward the end of life (EOL) in patients with solid cancers is debatable. This article is believed to be the first to report the current prevalence of EOL chemotherapy in China. This study found that, compared with oral anticancer agents, intravenous chemotherapy at the EOL was significantly associated with poor outcomes. Therefore, the role of oral anticancer agents at the EOL stage deserves further investigation.

Project description:ObjectiveTo analyze whether acute care patients with dementia are more or less likely to receive each of five aggressive medical services near the end of life, compared with patients without dementia.Data sourcesTwo years of Veterans Affairs (VA) and Medicare utilization data for all 169,036 VA users nationwide age 67 and older who died between October 1, 1999 and September 30, 2001.Study designWe performed a retrospective analysis of acute care stays discharged in the final 30 days of life. The main outcome measure was the patient's likelihood of receiving each of five aggressive services (intensive care unit [ICU] admission, ventilator, cardiac catheterization, pulmonary artery monitor, and dialysis), controlling for demographic and clinical factors in probit regressions.Principal findingsThere were 122,740 acute-stay discharges during the final 30 days of life, representing 94,100 unique patients (31,654 with dementia). In probit models comparing acute care patients with and without dementia, patients with dementia were 7.5 percentage points less likely to be admitted to the ICU (95 percent confidence interval [CI], 6.9-8.1; percent of stays with ICU admission=36.8 percent), 5.4 percentage points less likely to be placed on a ventilator (95 percent CI, 5.0-5.9; percent of stays with ventilator use=17.1 percent), 0.7 percentage points less likely to receive cardiac catheterization (95 percent CI, 0.6-0.8; percent of stays with cardiac catheterization=2.7 percent), 1.4 percentage points less likely to receive pulmonary artery monitoring (95 percent CI, 1.2-1.5; percent of stays with pulmonary artery monitoring=2.6 percent), and 0.6 percentage points less likely to receive dialysis (95 percent CI, 0.4-0.8; percent of stays with dialysis=4.6 percent).ConclusionsDuring the final 30 days of life, acute care patients with dementia are treated substantially less aggressively than patients without dementia. Further research is warranted to determine the causes and appropriateness of these patterns of care.

Project description:ObjectivesTo describe changes in the occurrence of restricting symptoms at the end of life from 1998 to 2019 and compare these changes according to the condition leading to death.DesignProspective longitudinal study.SettingGreater New Haven, CT.ParticipantsA total of 665 decedents from a cohort of 754 community-living persons, 70 years or older.MeasurementsThe occurrence of 16 restricting symptoms was ascertained during monthly interviews. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed every 18-months. For each restricting symptom, adjusted rates (per 100 person-months) were calculated separately for six multiyear time intervals.ResultsFrom 1998 to 2019, rates decreased for five (31.3%) restricting symptoms (difficulty sleeping; chest pain or tightness; shortness of breath; cold or flu symptoms; and nausea, vomiting, or diarrhea), increased for three (18.8%: arm or leg weakness; urinary incontinence; and memory or thinking problem), and changed little for the other eight (50.0%: poor eyesight; anxiety; depression; musculoskeletal pain; fatigue; dizziness or unsteadiness; frequent or painful urination; and swelling in feet or ankles). The decrease in rates was most pronounced for shortness of breath, with a reduction from 15.0 (95% credible interval = 11.7-18.6) in 1998 to 2001 to 8.2 (95% credible interval = 5.9-10.5) in 2014 to 2019, yielding a rate ratio (95% credible interval) of 0.92 (0.86-0.98). When evaluated according to the condition leading to death, the results were similar, with 10 of the 13 statistically significant rate ratios representing decreases in rates over time and only 3 representing increases.ConclusionThe occurrence of most restricting symptoms at the end of life has been decreasing or stable over the past two decades. These results suggest that end-of-life care has been improving, although additional efforts will be needed to further reduce symptom burden at the end of life.

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Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer.

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Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer.

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