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Research Letter |

Use of Chemotherapy Within the Last 14 Days of Life in Patients Treated at a Comprehensive Cancer Center FREE

Maria Alma Rodriguez, MD1; Alma Yvette DeJesus, RN, MSN2; Lee Cheng, PhD2
[+] Author Affiliations
1Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
2Department of Clinical Effectiveness, The University of Texas MD Anderson Cancer Center, Houston
JAMA Intern Med. 2014;174(6):989-991. doi:10.1001/jamainternmed.2014.1001.
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Published online

Evidence suggests that minimizing aggressive treatment for patients with terminal cancer may provide a better quality of life during the patients’ final days.1,2 One of the proposed metrics for determining quality of cancer care is whether chemotherapy is administered in the last 14 days of life.3 We assessed the proportion of patients who received chemotherapy in the last 14 days of life at our institution by diagnostic categories of solid tumor or hematologic malignant neoplasm and by factors with a potential influence on the use of chemotherapy.

This retrospective study examined a cohort of patients with cancer (aged ≥18 years) who received care at The University of Texas MD Anderson Cancer Center and died from December 1, 2010, through May 31, 2012. The study was approved by our institutional review board. We used χ2 tests to determine the association between categorical variables and applied a logistic regression model to factors that had a potential to influence chemotherapy use at the end of life. All statistical analyses were performed by using commercially available software (SAS, version 9.2; SAS Institute Inc).

We identified 7399 patients with cancer who met the inclusion criteria. Table 1 provides descriptive statistics on patients’ demographic characteristics and whether the patient was in an inpatient or other setting at the time of death. The percentages of patients receiving chemotherapy within the last 14 days of life are presented in Table 2. Overall, 7.4% received chemotherapy within the last 14 days of life. Chemotherapy was administered more frequently to patients with hematologic malignant neoplasms (24.8%) than to those with solid tumors (3.7%) (P < .001) and to those who died in the hospital (29.3%) than to those who died elsewhere (2.9%) (P < .01). Results of the multivariate model showed that patients who had solid tumors and metastatic disease or had hematologic malignant neoplasms (with or without relapse) were more likely to receive chemotherapy than were patients who had solid tumors without metastatic disease (odds ratios, 2.8, 16.5, and 33.1, respectively; P < .01). Overall, chemotherapy use at the end of life was less common in older patients (≥65 years) (odds ratio, 0.7; P < .01) and in patients with any comorbidities (odds ratio, 0.8; P < .01). No significant differences in chemotherapy use at the end of life were observed between the sexes or ethnic groups (all P > .05).

Table Graphic Jump LocationTable 1.  Characteristics of Adult Patients With Cancer Who Died During the Study Period
Table Graphic Jump LocationTable 2.  Patients With Cancer Receiving Chemotherapy Within 14 Days of the End of Life

We found overall that only a small proportion of our patients (7.4%) had received chemotherapy within 14 days of death. In this analysis from a single National Cancer Institute–designated Comprehensive Cancer Center, the proportion of patients with advanced solid tumors who had received chemotherapy within 14 days of death (3.7%) was significantly less than in an earlier report from Medicare claims data (20%).4 Older age and 1 or more comorbid conditions led to a statistically significant decrease in the use of chemotherapy at the end of life in our patients. On the other hand, almost one-fourth of the patients who died with a diagnosis of hematologic malignant neoplasm had received treatment within 14 days of the end of life, indicating a major difference in treatment practice for these disorders compared with solid tumors. Communication with patients about realistic prognosis, treatment planning, and advanced care planning is a critical component across the continuum of oncology care.5 A recent report issued by the Institute of Medicine specifically emphasizes that “[p]atients with advanced cancer should receive end-of-life care consistent with their needs, values, and preferences.”6 We hope that analysis and reporting of observed practice patterns and disease outcomes will drive discussions between physicians and patients that address realistic concerns and the patient’s values around end-of-life care.

Corresponding Author: Maria Alma Rodriguez, MD, Department of Lymphoma/Myeloma, Unit 1485, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 (marodriguez@mdanderson.org).

Published Online: April 21, 2014. doi:10.1001/jamainternmed.2014.1001.

Author Contributions: Drs Rodriguez and Cheng had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cheng.

Administrative, technical, or material support: Rodriguez, DeJesus.

Study supervision: Rodriguez.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This study was presented as a poster at the Annual Meeting of the American Society of Clinical Oncology; May 31-June 4, 2013; Chicago, Illinois.

Temel  JS, Greer  JA, Muzikansky  A,  et al.  Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
PubMed   |  Link to Article
Greer  JA, Pirl  WF, Jackson  VA,  et al.  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;30(4):394-400.
PubMed   |  Link to Article
American Society of Clinical Oncology. Quality Oncology Practice Initiative (QOPI®). Quality Measures. 2011. http://qopi.asco.org/. Accessed April 20, 2011.
Earle  CC, Neville  BA, Landrum  MB, Ayanian  JZ, Block  SD, Weeks  JC.  Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004;22(2):315-321.
PubMed   |  Link to Article
Smith  TJ, Temin  S, Alesi  ER,  et al.  American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.
PubMed   |  Link to Article
Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Press; 2013.

Figures

Tables

Table Graphic Jump LocationTable 1.  Characteristics of Adult Patients With Cancer Who Died During the Study Period
Table Graphic Jump LocationTable 2.  Patients With Cancer Receiving Chemotherapy Within 14 Days of the End of Life

References

Temel  JS, Greer  JA, Muzikansky  A,  et al.  Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
PubMed   |  Link to Article
Greer  JA, Pirl  WF, Jackson  VA,  et al.  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;30(4):394-400.
PubMed   |  Link to Article
American Society of Clinical Oncology. Quality Oncology Practice Initiative (QOPI®). Quality Measures. 2011. http://qopi.asco.org/. Accessed April 20, 2011.
Earle  CC, Neville  BA, Landrum  MB, Ayanian  JZ, Block  SD, Weeks  JC.  Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004;22(2):315-321.
PubMed   |  Link to Article
Smith  TJ, Temin  S, Alesi  ER,  et al.  American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.
PubMed   |  Link to Article
Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Press; 2013.

Correspondence

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