Racial Disparities in End-of-Life Care Among Patients With Prostate Cancer: A Population-Based Study.

OBJECTIVE: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). METHODS: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. RESULTS: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. CONCLUSIONS: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa.

Predicting life expectancy in patients with advanced incurable cancer: a review.

Oncologists frequently face the difficult task of estimating prognosis in patients with incurable malignancies. Their prediction of prognosis informs decision-making ranging from recommendations of cancer treatments to hospice enrollment. Unfortunately, physicians' estimates of prognosis are often inaccurate and overly optimistic. Further, physicians often fail to disclose their prognosis estimates, despite patient wishes to the contrary. Several studies have examined patient factors that might improve physicians' prognostic accuracy, including performance status, clinical symptoms and laboratory values. Prognostic models have been developed and validated but, to date, none are able to provide accurate estimates throughout the spectrum of advanced illness. This review examines tools utilized to predict life expectancy for patients with advanced, incurable cancer.

Survey Study of Awareness and Perception of Palliative and Hospice Care in a Cancer Center in Rural Pennsylvania.

Purpose: Hospice and palliative medicine (HPM) have been gaining ground especially in large urban settings. However, less is known about their perception in small rural areas. This study assessed the awareness and perception of a rural oncology population of this field and the effects of prognosis on their awareness. Methods: Subjects were patients of the community cancer center in rural Clarion County, Pennsylvania, who volunteered to complete a short nine-question survey (supplemental figure). Results were analyzed based on completed surveys. Results: A total of 65 surveys were collected from the Cancer Center at the Clarion Hospital. Among these patients, 54% stated that they have heard of palliative and hospice medicine. When correlating patient-reported prognosis with their awareness of palliative and hospice care, 100% of the patients with poor prognosis were aware of palliative or hospice care, respectively. In contrast, only <20% of patients with reported good prognosis were aware of HPM. Conclusions: Our study has shown that the awareness of HPM in rural areas is improving. It was observed that more patients are aware of HPM is when their prognosis was poor as compared with those who reported good prognosis.

Palliative Chemotherapy: Does It Only Provide False Hope? The Role of Palliative Care in a Young Patient With Newly Diagnosed Metastatic Adenocarcinoma.

Case Study A 48-year-old female with recent diagnosis of adenocarcinoma of unknown origin and metastatic disease to the peritoneum initially presented to a nearby academic hospital with abdominal pain. She underwent exploratory laparotomy with tumor debulking surgery at that time. Shortly thereafter, she was readmitted to the same hospital with evidence of partial small bowel obstruction and treated conservatively with bowel rest, nasogastric (NG) tube placement, and intravenous (IV) fluid administration. Eventually the NG tube was removed, and she was discharged home. The following day, she received cycle one of palliative chemotherapy with cisplatin and gemcitabine at her local outpatient oncology clinic. She experienced persistent nausea and intermittent vomiting throughout the night and presented to our local community hospital for evaluation. At the time of admission, she was passing minimal flatus and had passed only a small bowel movement that morning. She had experienced nausea, vomiting, and poor oral intake for over a week. Other presenting symptoms included mild to moderate abdominal pain involving the upper abdomen. Upon evaluation, abdominal x-ray revealed dilated loops of small bowel, consistent with partial small bowel obstruction. An NG tube was placed, and the patient's symptoms were initially improved with bowel rest. Her medical history was significant for pulmonary embolism detected at the time of her adenocarcinoma diagnosis, and she was on oral anticoagulation and home oxygen. She also had a history of depression and total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) due to fibroids. Her social history revealed she was an office worker and married with two sons, ages 18 and 24. The 18-year-old son lived at home with the patient and her husband. The patient was eagerly awaiting the birth of a granddaughter, due in a few weeks' time. Her mother and father were also present daily during her hospitalization and were a major source of support for her and her family. At the time of hospital admission, a surgical team consultation concluded she was not a candidate for palliative surgery due to extensive disease burden. She was seen in consultation by medical oncology, who recommended resuming chemotherapy once the acute partial small- bowel obstruction resolved. Palliative Care Consult A palliative care consultation was requested to assist with symptom management, including pain and nausea relief. At the time of consultation, the patient appeared in mild distress due to abdominal pain and distention. Vital signs were stable. Physical exam was significant for absent bowel sounds and a mildly distended but nontender abdomen. The NG tube was in place, draining bilious gastric fluid. She had mild nonpitting edema involving the bilateral lower extremities. Discussion with the patient revealed values consistent with improving symptoms and extending life expectancy as long as possible. The patient expressed wishes for "aggressive treatment," which she defined as continuation of chemotherapy and full resuscitation. The palliative care team discussed symptom management options with the patient. Nonsurgical management of partial bowel obstruction was continued, including bowel rest, NG tube decompression, and IV fluids. Pain was controlled initially with IV morphine as needed. After symptom improvement and evidence of bowel function recovery, the NG tube was removed. However, after a short time, she required NG tube replacement due to recurrent nausea and vomiting. Discussion was initiated with the patient, who opted for placement of a venting gastrostomy tube (G-tube) and total parenteral nutrition (TPN), with the goal of symptom relief and administration of nutrition, which would allow for continuation of chemotherapy. During placement of the venting G-tube, the gastroenterology (GI) team noted extensive tumor involving the stomach, which made placement of the tube difficult. Additionally, anticoagulation was held during G-tube placement, and postoperatively, the patient experienced acute, right-sided chest pain and shortness of breath. Computed tomography (CT) scan with pulmonary embolus (PE) protocol revealed a new PE, and anticoagulation was changed to enoxaparin. Shortly thereafter, she became febrile and developed leukocytosis. Blood cultures revealed coagulase-negative staphylococcus from a Port-a-Cath source. She was treated with appropriate antibiotic therapy; however, follow-up blood cultures revealed persistent coagulase-negative staphylococcus bacteremia. Her indwelling Port-a-Cath was removed. After appropriate antibiotic therapy, a peripherally inserted central catheter line was inserted and TPN restarted. Reinstituting Palliative Chemotherapy Palliative care discussion with the patient confirmed her desire to reinstitute palliative chemotherapy, with the goal of restoring bowel function and returning home. Chemotherapy was resumed on day 15, despite concerns and even objections from several nursing staff members. The patient experienced treatment side effects, including prolonged thrombocytopenia. A platelet function antibody returned positive, consistent with heparin-induced thrombocytopenia. Enoxaparin was discontinued, and fondaparinux (Arixtra) was initiated. Platelet count recovered shortly thereafter. The patient required intense symptom management due to intractable abdominal pain and nausea and vomiting despite adequate venting G-tube decompression. Medical management was maximized with antiemetics, antisecretory agents, steroids, and antipsychotic agents, and symptoms eventually improved after cycle 2 of chemotherapy. Thereafter, the patient was discharged home. At the time of discharge, her symptoms were well controlled on minimal pain medications. She was still experiencing intermittent nausea but was passing flatus. By reducing the tumor burden, chemotherapy significantly improved her quality of life. She spent a total of 7 weeks in the hospital. During that time, she received two cycles of chemotherapy plus best supportive care and symptom management. Despite intermittent nausea and vomiting, administration of palliative chemotherapy allowed this patient to achieve her primary goals, which included returning home to her family and regaining some bowel function. Over the next several months, she received several more cycles of outpatient palliative chemotherapy. She experienced mild to moderate nausea and intermittent vomiting despite G-tube venting. Eventually, her disease progressed, and the patient chose to forgo any further intervention or chemotherapy. She was enrolled in hospice care and died comfortably at home surrounded by her family.

The Intensive Palliative Care Unit: Changing Outcomes for Hospitalized Cancer Patients in an Academic Medical Center.

BACKGROUND: Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Women's Cancer Center, the intensive palliative care unit (IPCU) admits symptomatic oncology patients with uncontrolled symptoms throughout the trajectory of illness. Patients are uniquely managed by an interdisciplinary team of clinicians who focus on symptom management and advance care planning. OBJECTIVE: The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU. DESIGN: We retrospectively reviewed 74 oncology patients admitted to the IPCU in August and September, 2013. RESULTS: A total of 67 IPCU patients who were admitted received palliative intent treatment, whereas 7 patients received curative intent care. All patients were engaged in a goals-of-care discussion during admission. Of the palliative intent patients, 58% were transferred to the IPCU from medical oncology and 42% were directly admitted. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint at admission. Twenty-five patients experienced a change in code status from Full Code to do-not-resuscitate/do-not-incubate. A total of eight patients died in the IPCU, and 50% experienced a code status change. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30-day readmission was 4%. CONCLUSIONS: Among advanced cancer patients, our findings suggest that an inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases hospital readmissions.

Chemotherapy for advanced cancers.

The decision to treat with chemotherapy in advanced cancers is a complex process that requires oncologists to weigh the indications and benefits. Treatment of patients with advanced cancer is typically multidimensional and should ideally include oncologists in coordination with palliative care specialists. When the intent of chemotherapy for patients with advanced neoplasms is no longer curative, palliative care can and should be delivered simultaneously with antineoplastic agents. Often, chemotherapy for advanced cancers is delivered in an attempt to palliate symptoms, and therefore improve quality of life (QOL). The role of palliative chemotherapy should be continually reevaluated throughout the trajectory of the patient's illness. When chemotherapy is no longer controlling the disease or helping symptoms, the role of chemotherapy should be reconsidered. This review aims to provide a foundation for discussions about treatment of patients with advanced malignancies.

Bridging the gap: a palliative care consultation service in a hematological malignancy-bone marrow transplant unit.

BACKGROUND: There is often a lack of collaboration between hematological malignancy-bone marrow transplantation (HM-BMT) units and palliative care (PC) services. In this paper, we describe a quality improvement project that sought to close this gap at a tertiary care hospital in Pittsburgh, Pennsylvania, from August 2006 to May 2010. DESIGN AND METHODS: Through a needs assessment, didactic lectures, clinical consultation, and the informal presence of PC clinicians, the team created a palliative care service in HM-BMT unit of the Western Pennsylvania Hospital in Pittsburgh. The following data were collected for each consult: referral reason, daily pain assessments, whether or not a "goals of care" conversation took place, and hospice enrollment. Lastly, satisfaction surveys were administered. RESULTS: During the program, 392 PC consultations were provided to 256 unique patients. Of these 256 patients, the PC clinicians documented the first goals of care conversations in 67% of patients (n = 172). Of the 278 consults referred for pain, 70% (n = 194) involved reports of unacceptable or very unacceptable pain at baseline. Sixty-six percent (n = 129) of these 194 consults involved reports of pain that was acceptable or very acceptable within 48 hours of consultation. In addition, the hospice referral rate grew from a pre-implementation rate of 5% to 41% (n = 67) of 165 patients who died during the period of program implementation. Lastly, hematological oncologists reported high levels of satisfaction with the program. LIMITATIONS: The main limitation of this project is that it was a single institution study. CONCLUSION: The successful integration of a PC team into a hematological malignancy unit suggests great potential for positive interdisciplinary collaboration between these two fields.

Metastatic spinal cord compression: the hidden danger.

BACKGROUND: A 47-year-old male underwent resection of a left-shoulder melanoma in 1997. In November 2004 he was found to have multiple brain lesions and adrenal, lung, and bone metastases, and in January 2005 underwent resection of his symptomatic right parietal lobe lesion and subsequent whole-brain radiation. In February 2005 he experienced headaches and word-finding difficulty and was found to have four progressive brain lesions on MRI. These were resistant to conventional radiotherapy and were treated with stereotactic radiosurgery. The patient later developed an obstruction of the jejunum and underwent resection of multiple abdominal masses. In April 2005, the patient commenced temozolomide and underwent radiation therapy to the left arm for pain thought to be caused by an increase in size of his melanoma metastasis. In August 2005 the patient reported persistent and worsening arm pain, despite a further course of radiotherapy in June 2005. INVESTIGATIONS: Physical examination including a thorough neurological examination, radiography, X-ray, CT scan, and MRI. DIAGNOSIS: Metastatic melanoma to the cervical spine (C7 vertebra) with spinal cord compression. MANAGEMENT: Involved field radiotherapy, temozolomide, opioids, gabapentin, corticosteroids, and Cyberknife therapy.