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Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer.

J Clin Oncol. 2012 Feb 1;30(4):394-400

Authors: Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Heist RS, Gallagher ER, Temel JS

Abstract
PURPOSE: Prior research shows that introducing palliative care soon after diagnosis for patients with metastatic non-small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. We sought to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients.
PATIENTS AND METHODS: This secondary analysis is based on a randomized controlled trial of 151 patients with newly diagnosed metastatic NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009. Participants received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included: first, number and types of chemotherapy regimens, and second, frequency and timing of chemotherapy administration and hospice referral.
RESULTS: The overall number of chemotherapy regimens did not differ significantly by study group. However, compared with those in the standard care group, participants receiving early palliative care had half the odds of receiving chemotherapy within 60 days of death (odds ratio, 0.47; 95% CI, 0.23 to 0.99; P = .05), a longer interval between the last dose of intravenous chemotherapy and death (median, 64.00 days [range, 3 to 406 days] v 40.50 days [range, 6 to 287 days]; P = .02), and higher enrollment in hospice care for longer than 1 week (60.0% [36 of 60 patients] v 33.3% [21 of 63 patients]; P = .004).
CONCLUSION: Although patients with metastatic NSCLC received similar numbers of chemotherapy regimens in the sample, early palliative care optimized the timing of final chemotherapy administration and transition to hospice services, key measures of quality end-of-life care.

PMID: 22203758 [PubMed - indexed for MEDLINE]

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National trends in lung cancer surgery.

Eur J Cardiothorac Surg. 2012 Aug;42(2):355-8

Authors: Strand TE, Bartnes K, Rostad H

Abstract
OBJECTIVES: Trends in lung cancer surgery may reveal potential for improvement and are important for planning by care providers.
METHODS: Using data from the Cancer Registry of Norway, we analysed the outcomes of lung cancer surgery during the periods of 1994-95, 2000-01 and 2006-07. The Cox regression model was carried out to identify the period effect on survival.
RESULTS: A total of 2201 patients were operated on. Surgery was centralized from 24 hospitals in the first two periods to 13 hospitals in the last. The resection rates varied from 6 to 31% across the counties. From the first to the last period, the national resection rate increased from 16 to 19% (P(trend) = 0.001), and the 1-year survival rate increased from 73 to 82%. The proportion of resected patients in pathological stage I-II decreased from 87 to 83% (P(trend) = 0.048), the proportion of pneumonectomies from 27 to 15% (P(trend)<0.001), and the rate of mortality within 30 days of the surgery from 4.8 to 3.0% (P(trend) = 0.072). In the first two periods, 31% of these early deaths were caused by complications directly related to the surgical technique, whereas, in the latter period, no deaths were directly related. The only unfavourable trend was the waiting time between the final diagnostic procedure and surgery, which increased from 29 to 40 days throughout the three periods (P < 0.001). Survival (excluding those who died within 30 days) was significantly improved in the last period (risk ratio (RR): 0.72 (P < 0.001)).
CONCLUSIONS: Despite an increased surgical waiting time, important aspects of lung cancer surgery, including resection rates, have improved in recent years.

PMID: 22402451 [PubMed - indexed for MEDLINE]

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Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study.

J Clin Oncol. 2012 Dec 10;30(35):4387-95

Authors: Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, Earle CC, Weeks JC

Abstract
PURPOSE National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death. PATIENTS AND METHODS We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system-based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received. Results Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001). CONCLUSION Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.

PMID: 23150700 [PubMed - in process]

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Targeted Agent Use in Cancer Patients at the End of Life.

J Pain Symptom Manage. 2012 Nov 9;

Authors: Hui D, Karuturi MS, Tanco KC, Kwon JH, Kim SH, Zhang T, Kang JH, Chisholm G, Bruera E

Abstract
CONTEXT: The use of targeted therapy at the end of life has not been well characterized. OBJECTIVES: To determine the frequency and predictors of targeted therapy use in the last days of life. METHODS: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents. RESULTS: Eight hundred sixteen patients were included: average age 62 years (range 21-97), female 48% and white 61%. The median interval between the last treatment and death was 47 (interquartile range [IQR] 21-97) days for targeted agents and 57 (IQR 26-118) days for chemotherapeutic agents. Within the last 30 days of life, 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy. Regimens given in the last 30 days of life included a median of one (IQR 1-2) chemotherapeutic or targeted agents, and 43 (5%) patients receiving targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n = 25), bevacizumab (n = 20), rituximab (n = 11), gemtuzumab (n = 8), and temsirolimus (n = 8). On multivariate analysis, younger age (odds ratio [OR] 0.98 per year, P = 0.01), hematologic malignancy (OR = 6.1, P < 0.001), and lung malignancy (OR = 2.6, P = 0.05) were associated with increased targeted agent use in the last 30 days of life. CONCLUSION: Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed.

PMID: 23211648 [PubMed - as supplied by publisher]