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How Much Chemotherapy Are Cancer Patients Receiving at the End of Life?

Heather Jones, MD

University of Pennsylvania Cancer
Ultima Vez Modificado: 12 de mayo del 2001

Presenter: E.J. Emanuel
Affiliation: National Institutes of Health

Background:

End of life issues are an important part of oncology care. This study was performed to determine the proportion of cancer patients getting chemotherapy at the end-of-life, their characteristics, and how chemotherapy relates to receiving hospice.

Materials and Methods:

Linking HCFA files with 1996 Massachusetts death certificates identified 34,131 Medicare FFS decedents enrolled for 12 months, with 7,919 (23%) cancer decedents.

Results:

• 41% of Medicare cancer patients had chemotherapy in last the year, 26% in the last 3 months, and 14% in the last month of life.
• Males were more likely than females (43% v.39%, p< O.O5) and younger than older decedents (54% 65- 74 v.39% 75-84, p< O.05) to receive chemotherapy. For patients 85 and older, 23% received chemotherapy in the last year of life and 12% in the last 3 months.
• Patients with hematological malignancies received chemotherapy most frequently in the last 12, 3, and 1 months of life: 58%, 45%, and 28% respectively.
• Patients with solid tumors received chemotherapy less frequently in the last 12, 3, and 1 months of life: lung 36%, 21% and 11%; colon 41%, 26%, and 11%; breast 41%, 25%, 13%; pancreas 38%, 27%, 14%, respectively.
• Patients with known unresponsive tumors were just as likely to receive chemotherapy in the last months of life as patients with responsive tumors.
• Patients receiving chemotherapy had significantly higher expenditures in the last year of life compared to those who did not: $38,308 vs. $27,567.
• 33% of decedents utilized hospice, and 16% received both chemotherapy and hospice.
• Patients who received chemotherapy in the last month of life were enrolled in hospice 39 days later and those who received chemotherapy in the last 3-6 months of life were enrolled in hospice 12 days later compared to patients who did not have chemotherapy in the last year of life.

Authors' Conclusions

• A large proportion of patients receive chemotherapy in the last 12, 3, and 1 month of life.
• Patients that get chemotherapy are more likely to use hospice, but for shorter duration.

Clinical/Scientific Implications:

1. This is a very provocative study that suggests that there may be over use of chemotherapy in the last months of life, particularly in patients with unresponsive tumors. However, it is important to note that population studies based on billing, cannot factor in issues such as patient performance status, attempts at palliation, and patient/family preferences when an oncologist decides to use chemotherapy in the last months of life.

2. In addition, on a more practical note, it is difficult if not impossible to determine the amount of chemotherapy given to a patient in terms of cycles of chemotherapy from billing data. In this study the chemotherapy use was defined as months of use (2 claims in 30 days). One wonders if such a definition is truly an accurate measure of chemotherapy use.