The Impact of Palliative Care and Hospice Services in the Care of Patients with Advanced Stage Non-Small Cell Lung Cancer
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1 The Impact of Palliative Care and Hospice Services in the Care of Patients with Advanced Stage Non-Small Cell Lung Cancer Richard C. Stephenson, MD Hospice & Palliative CareCenter Amy H. Hughes Forsyth Regional Cancer Center Kristy Tayapongsak, MSII Wake Forest School of Medicine
2 Overview Background & Literature Review Study Sample & Methods Our Findings: How do we measure up? Conclusions: Maximizing Strengths, Minimizing Weaknesses Next Steps Research & Clinic
3 Lung Cancer Introduction 2 nd most common cancer diagnosis Leading cause of cancer-related deaths Non-Small Cell Lung Cancer (NSCLC) Most common type Often initially presents with distant metastases Stage IV Incurable -opens the door for palliative care soon after diagnosis
4 Literature Review The Palliative Care Tree Palliative Care Consult: 1. Patient education 2. Symptom management 3. Coping with terminal illness 4. Treatment decisionmaking 5. Future appointments and referrals
5 Effects of Early Palliative Care TemelJS, Greer JA, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-smallcell lung cancer: results of a randomized study of early palliative care. J. Clin Oncol. 29(17): , metastatic NSCLC patients 1/3 of patients reported that their cancer was curable Majority of patients endorsed getting rid of all the cancer as a goal of therapy Realistic understanding of prognosis is crucial to medical decision making!
6 Early Palliative Care Intervention More Accurate Perception of Prognosis ( Incurable ) Less Likely to Receive Intravenous Chemotherapy Near the End of Life
7 The value of chemo in this diagnosis? Brown J, Thorpe H, Napp V, et al. Assessment of quality of life in the supportive care setting of the Big Lung Trial in nonsmall-cell lung cancer. J. Clin Oncol. 23: , patients No chemo vs. chemo Chemo only gave modest gains in survival Chemo did NOT negatively impact global quality of life, physical/emotional functioning, fatigue, dypsnea, or pain in cancer patients Chemo CAN play a palliative role, but not a curative one There is no longer a basis for failure to offer chemotherapy to patients in the supportive care setting.
8 Effects of Early Palliative Care 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. 30: , metastatic NSCLC patients Early palliative care intervention vs. standard care alone Both groups received similar numbers of chemotherapy regimens BUT Optimized timing of final chemotherapy administration Longer treatment-free interval between last infusion dose and death Earlier transition to hospice services
9 Effects of Early Palliative Care TemelJS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 363: , patients diagnosed with metastatic NSCLC between Palliative care + standard care vs. standard care alone survival prolonged by 2 months clinically meaningful improvements in quality of life and mood
10 An economic benefit, too! Given the trends toward aggressive and costly care near the end of life among patients with cancer, timely introduction of palliative care may serve to mitigate unnecessary and burdensome personal and societal costs. -Temelet al., 2010
11 Literature Review: Early Palliative Care Incorporation of palliative care ALONGSIDE standard oncological care for NSCLC patients median survival quality of life accuracy of illness percep on aggressive treatment at end of life depressive symptoms
12 Literature Review: Hospice services Saito AM, Landrum MB, Neville BA, et al. Hospice care and survival among elderly patients with lung cancer. J Palliat Med. 14(8): , Retrospective study of 7879 advanced NSCLC lung cancer patients Hospice patients had a longer survival than nonhospice patients! Statistically significant for long-term hospice patients Concern about hastening death should not be a barrier to hospice care.
13 And yet TemelJS, McCannonJ, Greer JA, et al. Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer. 113(4): , Study provides baseline data describing care for advanced stage NSCLC patients: increasingly aggressive treatment towards the end of life high rates of chemotherapy usage near EOL high rates hospital admissions near EOL percentage of patients referred to hospice before death, but length of stay in hospice the current climate of oncology care for patients with late-stage lung cancer is arguably an aggressive one.
14 Where the hospice stigma is coming from Earle CC, Landrum MB, Souza JM, et al. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J. Clin Oncol. 26(23): , This pattern of increased overall useof hospice, but decreased length of stay. patients are simply being admitted to hospice to manage death, rather than obtaining the benefits of symptom management and palliative support that hospice can provide.
15 More to this life Emerging key measure of excellence in cancer care: quality of end of life surveys of patients, families, and clinicians affirming the value of not simply prolonging lifebut also enhancing the dying process Temelet al., 2008
16 So how do we measure up? Research Aims: 1. Profilethe continuum of care for advanced stage NSCLC patients. 2. Compareour findings to national benchmarks.
17 Study Sample 119 deceased stage IV NSCLC patients Diagnosed at Forsyth Regional Cancer Center (FRCC) 2008, 2009, 2010 Reside in Forsyth Co.
18 Methods Retrospective Chart Review antitumor treatment services post-diagnosis hospital, ED, ICU admissions Electronic Medical Records Forsyth Medical Center (FMC) Rad Onc Med Onc Acute Palliative Care Unit HPCC palliative care consultations hospice referrals & enrollments circumstances surrounding death
19 Methods National Benchmarks from QOPI and published studies Natl Benchmarks (<%) >1 emergency room visit in the last month of life % >1 hospitalization in the last month of life % Admission to ICU in last month of life % Proportion starting a new chemotherapy regimen in the last 30 days of life % Proportion receiving chemotherapy in the last 14 days of life % Lack of hospice enrollment % Admission to hospice <3 days before death % Admission to hospice <7 days before death % Death in an acute care hospital % 1 Quality Oncology Practice Initiative Aggregate Data from Spring Greer et al., Earle et al., 2005
20 Results Median survival: 125 days (4.1 months) Range: 3 days 3.2 years 81.5% received antitumor treatment RT, Chemo, or Both 14 out of 119 patients (11.76%) received extensive chemotherapy (3, 4, or 5 lines of chemo)
21 0/1/2 Lines of Chemo Median Age: 71 y/o Race Black: 16.35% White: 83.65% 3/4/5 Lines of Chemo Median Age: 62 y/o Younger patients received more extensive chemo treatment. Race Black: 28.57% White: 71.43% Twice as many black patients received extensive chemo treatment. Lines of Chemo: By Age Lines of Chemo: By Race Proportion of Patients (%) < 50 y/o Age in Years 0,1,2 lines of chemo 3,4,5 lines of chemo Proportion of Patients (%) 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% White Black
22 On track with the literature Miesfeldt S, Murray K, Lucas L, et al. Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J of Palliative Medicine. 15(5), Utilized similar benchmarks to define aggressive management less chemotherapy use at EOL less late-life acute care greater use of hospice services Less likely to receive aggressive management if: Older ( 75 y/o) Female Nonblack
23 EOL Cancer Care Measures: National Benchmarks vs. Forsyth Co. Proportion of Patients (%) 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 4% 4% 4% 2% 12% 9% 8% 5% 5% 3% 43% 27% 15% 9% 29% 21% 26% 27% Natl Benchmarks Forsyth County
24 EOL Cancer Care Measures: National Benchmarks vs. Forsyth Co. Proportion of Patients (%) 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 4% 4% 4% 2% 12% 9% 8% 5% 5% 3% 43% 27% 15% 9% 29% 21% 26% 27% Natl Benchmarks Forsyth County
25 EOL Cancer Care Measures: National Benchmarks vs. Forsyth Co. Proportion of Patients (%) 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% p=0.02 4% 4% 4% 2% 12% 9% 8% 5% 5% 3% 43% 27% 15% 9% 29% 21% 26% 27% Natl Benchmarks Forsyth County
26 Results 28% received palliative care consult Early palliative care consultation 1 patient 79% received hospice referral 73% enrolled into hospice services Median length of stay: 23 days (compared to 9.3 days)
27 Patient Variables: Non-Hospice vs. Hospice Patients Non-Hospice Patients (n=32) Mean Age: 68 y/o Race Black: 15.63% White: 84.38% Hospice Patients (n=87) Mean Age: 69 y/o Race Black: 18.60% White 81.40%
28 90.00% EOL Cancer Care Measures: Non-Hospice vs. Hospice Patients Proportion of Patients (%) 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% Benchmark (<%) Forsyth Co. - Non-Hospice Forsyth Co. - Hospice 10.00% 0.00% >1 ED visit w/in last month >1 hospitalization w/in last month ICU w/in last month New Chemo Chemo - 14 days w/in last month of death Death in hospital
29 Proportion of Patients (%) 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% EOL Cancer Care Measures: Non-Hospice vs. Hospice Patients p=0.01 p=0.005 p=0.005 p=0.001 Benchmark (<%) Forsyth Co. - Non-Hospice Forsyth Co. - Hospice 10.00% 0.00% >1 ED visit w/in last month >1 hospitalization w/in last month ICU w/in last month New Chemo Chemo - 14 days w/in last month of death Death in hospital Hospice patients did better than non-hospice patients across all measures!
30 Location of Death: Non-Hospice vs. Hospice Patients Non-Hospice Patients Acute care hospital: 78.13% Hospice Patients Acute care hospital: 8.05% Nursing Home 3% p=0.001 Nursing Home 2% Hospital: Inpatient 2% Hospital: ER 2% Hospital: ICU 1% Home 19% Hospital: APCU 4% Hospital: APCU 16% Hospital: Inpatient 47% Hospice: Inpatient 50% Home 39% Hospital: ICU 6% Hospital: ER 9%
31 Median Survival Non-Hospice Patients (n=32) Median survival: 103 days Hospice Patients (n=87) Median survival: 134 days p = 0.06 (ALMOST!) Median Number of Days From Diagnosis To Death Hospice: 134 Non-Hospice: Number of Days
32 What about trends over time?
33 Moving Towards Palliative Care? 90.00% 80.00% 80.00% 87.80% Proportion of Patients (%) 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 20.00% 27.91% 69.77% 36.59% Received PC Consult Received Hospice Referral 0.00%
34 Median Number of Days from Diagnosis to Death and Days in Hospice: Forsyth Co. By Year Number of Days Days between Dx Death LOS in Hospice
35 Conclusions We re doing well! But there s always room for improvement! Oncological Treatment at End of Life Early Use of Palliative Care Consultation Hospice Services Referrals & Enrollment Length of Stay
36 Research Next Steps Repeat study at the Comprehensive Cancer Center at Wake Forest Baptist Health Academic hospital vs. community hospital? Patients who seek care in an academic medical setting with active research programs may be more likely to receive aggressive care -Temelet al., 2008
37 Clinic Next Steps Patients may have received late referrals to hospice because they were already receiving sufficient EOL support through palliative care intervention. Perhaps outpatient palliative servicesmay be a solution to bridge critical gaps in care -Temelet al., 2008 And that s exactly what we re doing! Outpatient Palliative Care Consultation Program currently in the works at FRCC Earlier referrals to HPCC Not just a last resort
38 References 1. Brown J, Thorpe H, Napp V, et al. Assessment of quality of life in the supportive care setting of the Big Lung Trial in non-small-cell lung cancer. J. Clin Oncol. 23: , Earle CC, Landrum MB, Souza JM, et al. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J. Clin Oncol. 26(23): , Earle CC, Neville BA, Landrum MB, et al. Evaluating claims-based indicators of the intensity of end-of-life cancer care. International Journal for Quality in Health Care. 17(6): , 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. 30: , Miesfeldt S, Murray K, Lucas L, et al. Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J of Palliative Medicine. 15(5), Podnos YD, Borneman TR, Koczywas M, et al. Symptom concerns and resource utilization in patients with lung cancer. J Palliat Med. 10(4): , Quality Oncology Practice Initiative Aggregate Data from Spring 2012.
39 References 8. Quill, TE. Is length of stay on hospice a critical quality of care indicator? J Palliat Med. 10(2): , Saito AM, Landrum MB, Neville BA, et al. Hospice care and survival among elderly patients with lung cancer. J Palliat Med. 14(8): , Siegel R, Naishadham D, Jemal A. Cancer statistics, CA: A Cancer Journal for Clinicians. 62: 10 29, Spiro SG, Rudd RM, Souhami RL, et al. Chemotherapy versus supportive care in advanced non-small cell lung cancer: improved survival without detriment to quality of life. Thorax. 59: , Temel JS, Greer JA, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J. Clin Oncol. 29(17): , Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 363: , Temel JS, McCannon J, Greer JA, et al. Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer. 113(4): , 2008.
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