Care Among Patients Treated at a Comprehensive Cancer Center

Background. Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral. Methods. We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death. Results. In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5–4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6–45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC. Conclusions. We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral. The Oncologist 2012;17: 1574–1580 INTRODUCTION Patients with advanced cancer have many significant physical and psychological symptoms including pain, fatigue, weight loss, lack of appetite, nausea, shortness of breath, depression, anxiety, and confusion [1]. These symptoms often have a major impact on patients’ quality of life [2]. Therefore, good control of these symptoms is one of the most important aspects of the care of advanced cancer patients and requires comprehensive interdisciplinary care. Palliative care (PC) by a comprehensive interdisciplinary team has been shown to provide effective symptom management [3–5]. In fact, PC has become an important part of the continuum of care for cancer patients, and many studies have demonstrated benefits such as improvements in quality of life, Correspondence: David Hui, M.D., M.Sc., The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, Texas 77030, USA. Telephone: 713-792-6084; Fax: 713-792-6092; e-mail: dhui@mdanderson.org Received May 3, 2012; accepted for publication July 26, 2012; first published online in The Oncologist Express on December 7, 2012. ©AlphaMed Press 10837159/2012/$20.00/0 http://dx.doi.org/10.1634/theoncologist.2012-0192 The Oncologist Symptom Management and Supportive Care The Oncologist 2012;17:1574–1580 www.TheOncologist.com by gest on Jauary 5, 2018 http://thologist.alpham edpss.org/ D ow nladed from various physical and psychosocial symptoms, and survival outcomes [4, 6–9]. However, the appropriate timing of PC referral remains unclear. In a recent randomized controlled trial, patients with metastatic non-small cell lung cancer assigned to PC within 8 weeks of their cancer diagnosis had a better quality of life [10]. However, PC is still routinely delivered very late in the disease trajectory to patients who have advanced cancer [11]. The short amount of time for interaction with the PC team significantly limits the effectiveness of such services [6, 12, 13]. Although multiple studies have examined the timing of PC referral among patients who received PC [12, 14–16], there is a paucity of studies on the actual proportion of cancer patients who access PC and the predictors of PC referral. We only identified a few studies that explored population databases [17, 18] and surveyed families of cancer patients [19, 20], although they did not assess PC referral patterns from an institutional perspective. Our institution is a National Cancer Institute designated comprehensive cancer center and includes an active PC program consisting of three mobile teams, an acute PC unit, and a supportive care clinic. An examination of the PC referral pattern at our institution would help characterize referral patterns while controlling for an important variable, PC availability. The objective of this retrospective study is to estimate the proportion of patients seen at MD Anderson Cancer Center (MDACC) who died of cancer and had access to PC services and to identify predictors of PC referral. PATIENTS AND METHODS We reviewed the medical records of 1,691 consecutive MDACC patients who died as a result of advanced cancer between September 1, 2009 and February 28, 2010 and had a postal address within the seven-county Houston metropolitan area, which was defined as the central county (Harris) and the seven surrounding counties (Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller). Patients aged 18 years, who did not die as a result of advanced cancer, or who had last contact with MDACC 3 months before death were excluded. The first date was chosen to ensure that all medical records would be available in the hospital’s electronic medical records system. The second date was chosen to ensure that the deaths could be confirmed on the Social Security Death Index interactive search by the time we started the data collection. Geographic restriction was used to ensure that patients had the opportunity for regular follow-up at our cancer center. This retrospective study was approved by our institutional review board. For the purpose of this study, we defined advanced cancer as locally advanced, metastatic, or recurrent disease for solid tumors and as incurable disease at presentation (e.g., myeloma, advanced stage low-grade lymphoma) or first relapse for hematologic malignancies. We also included patients who refused all curative treatments, patients who were referred to the phase I program, and patients who, according to the oncologists’ notes, had an incurable (or refractory) cancer or were not eligible for potentially curative treatment (e.g., because of a low performance status or comorbidities). For patients with multiple malignancies, we used only data regarding the cancer most responsible for the patient’s death. Five PC specialists and oncologists reviewed the 1,691 medical records to identify the date of advanced cancer and the first consult date of PC services if patients had a PC consultation. Educational level was extracted manually from electronic medical records. The information collected by informatics department staff from medical records included patient demographics (age, sex, ethnicity, religion, and marital status), date of birth, date of death, postal address and county, cancer location and type, oncology service team, date of entry into the MDACC registry, and date of cancer diagnosis. We also collected information about the number of encounters with the medical team by reviewing billing records for the intervals between the advanced cancer diagnosis and death for patients who did not receive PC services and between the advanced cancer diagnosis and first PC consultation and death for patients who received PC services. Statistical Analysis We summarized the baseline demographics using descriptive statistics, including medians, interquartile ranges, means, ranges, frequencies, and percentages. We compared the baseline characteristics between patients with and without PC encounters. Comparisons were made using Student’s t-test for continuous variables that were normally distributed (e.g., age), the Mann-Whitney test for continuous, nonparametric variables (e.g., the interval between an advanced cancer diagnosis and death, number of clinic visits), and the 2 test or Fisher’s exact test for categorical variables (e.g., sex, race). We also compared the time interval between and the number of clinic visits before and after PC consultation using the Wilcoxon rank sum test for paired analysis. To identify independent factors associated with PC referral, all variables with a p-value .10 on univariate analysis were included in a multivariate logistic regression model using backward selection. The timing of PC referral was examined based on (a) the time from an advanced cancer diagnosis to PC consultation and (b) the overall survival duration from the time of PC consultation. The overall survival time was calculated from the date of PC referral to the date of death. All time-event analyses were examined using the Kaplan–Meier method and survival curves were compared using the log-rank test. A two-sided p-value .05 was considered to be statistically significant. The Statistical Package for the Social Sciences (IBM SPSS version 19.0, SPSS Inc., Chicago, IL) software was used for statistical analysis.