Impact of treatment delay on survival of oral/oropharyngeal cancers: Results of a nationwide screening program.

BACKGROUND: To assess the impact of treatment delay on survival of oral/oropharyngeal cancer (OSCC). METHODS: We followed 5743 OSCCs between 2004 and 2009 from a population-based screening program and ascertained death until the end of 2012. RESULTS: The hazard ratios (HRs) of mortality from OSCC were 1.46 (1.30-1.65) and 1.18 (1.04-1.33) in univariable and multivariable analyses, respectively, for treatment delay longer than 6 weeks compared with that shorter than 3 weeks. The corresponding figures were 1.12 (1.01-1.24) and 1.00 (0.91-1.11) for treatment delay between 3 and 6 weeks. Advancing age (1.01), higher stage (stage II: 1.84, stage III: 2.97, stage IV: 6.33), cancer in tongue (1.37), or hard palate (1.63) had higher HR of mortality (P < .05). However, treatment at medical center had a lower mortality (0.83, 0.75-0.91) than local/regional hospital. CONCLUSIONS: Treatment delay longer than 6 weeks for OSCCs detected via a population-based screening program had unfavorable survival.

Effectiveness of Japanese SHARE model in improving Taiwanese healthcare personnel's preference for cancer truth telling.

BACKGROUND: Communication skills training (CST) based on the Japanese SHARE model of family-centered truth telling in Asian countries has been adopted in Taiwan. However, its effectiveness in Taiwan has only been preliminarily verified. This study aimed to test the effect of SHARE model-centered CST on Taiwanese healthcare providers' truth-telling preference, to determine the effect size, and to compare the effect of 1-day and 2-day CST programs on participants' truth-telling preference. METHOD: For this one-group, pretest-posttest study, 10 CST programs were conducted from August 2010 to November 2011 under certified facilitators and with standard patients. Participants (257 healthcare personnel from northern, central, southern, and eastern Taiwan) chose the 1-day (n = 94) or 2-day (n = 163) CST program as convenient. Participants' self-reported truth-telling preference was measured before and immediately after CST programs, with CST program assessment afterward. RESULTS: The CST programs significantly improved healthcare personnel's truth-telling preference (mean pretest and posttest scores ± standard deviation (SD): 263.8 ± 27.0 vs. 281.8 ± 22.9, p < 0.001). The CST programs effected a significant, large (d = 0.91) improvement in overall truth-telling preference and significantly improved method of disclosure, emotional support, and additional information (p < 0.001). Participation in 1-day or 2-day CST programs did not significantly affect participants' truth-telling preference (p > 0.05) except for the setting subscale. Most participants were satisfied with the CST programs (93.8%) and were willing to recommend them to colleagues (98.5%). CONCLUSIONS: The SHARE model-centered CST programs significantly improved Taiwanese healthcare personnel's truth-telling preference. Future studies should objectively assess participants' truth-telling preference, for example, by cancer patients, their families, and other medical team personnel and at longer times after CST programs.

Use of chemotherapy at the end of life among Taiwanese cancer decedents, 2001-2006.

INTRODUCTION: The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. Use of chemotherapy near the end of life may not benefit cancer patients. However, no population-based study has examined the determinants for continuing chemotherapy at the end of life for all ages and cancer groups as well as for a whole country. This population-based study assessed the association between continuation of chemotherapy in the last month of life and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and healthcare resource availability at the hospital and regional levels. MATERIALS AND METHODS: Retrospective population-based cohort study using administrative data among 204 850 Taiwanese cancer decedents in 2001-2006. RESULTS: Rates of continued chemotherapy in the last month of life for each study year were 17.5%, 17.4%, 17.3%, 19.0%, 20.0%, and 21.0%, respectively and have remained steady since 2001. Taiwanese cancer patients had greater odds for continuation of chemotherapy in the last month of life if they were male [adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.13-1.25], younger, single [1.21 (1.09-1.35)], had lower comorbidity levels, were diagnosed with hematologic malignancies [1.90 (1.09-1.35)] and breast cancer [1.24 (1.08-1.43)], had metastatic disease [1.36 (1.27-1.46)], and survived < 1 year but longer than two months post-diagnosis. The odds for continued chemotherapy in patients' last month was significantly increased by being cared for by a medical oncologist [3.49 (3.04-3.99)] or in a teaching hospital [1.39 (1.11-1.74)] and with the highest intensity of total inpatient hospital beds [1.63 (0.99-2.68)], but was not influenced by regional healthcare resources (total hospital and hospice beds). CONCLUSION: The relative risk for continuation of chemotherapy in the last month of life was determined by patient demographics and disease characteristics, physician specialty, and healthcare resources at the primary hospital level.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006.

BACKGROUND: With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated. PURPOSE: To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients. METHODS: Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years. RESULTS: Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life. CONCLUSION: Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006.

CONTEXT: Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals. OBJECTIVES: To investigate the impact of an inpatient hospice unit on the parent hospital's quality of palliative care. METHODS: This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001-2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend. RESULTS: Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit. CONCLUSION: Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients' characteristics.

Hospice utilization in Taiwan by cancer patients who died between 2000 and 2004.

To facilitate utilization of hospice services, Taiwan uses the National Health Insurance (NHI) as a major policy instrument. To evaluate the effect of this policy on hospice utilization by cancer patients during their final year of life, a retrospective cohort study was conducted by linking individual patient-level data from the National Register of Deaths Database and the NHI claims database to examine changes in the rates of hospice utilization, durations of patient survival (DOS) after enrollment, and the rates of late referrals to hospice care from 2000 to 2004. Among the 103,097 cancer patients who died between 2000 and 2004, the rate of hospice utilization during their final year of life grew substantially from 5.5% to 15.4%. However, Taiwanese cancer patients were enrolled in hospice care close to death (median DOS ranged from 14 to 47 days). Except for the small proportion of patients who received both inpatient hospice care and hospice home care, one-third to one-fourth of cancer decedents died within 7 days after being enrolled in hospice care. Although the rate of late referrals to hospice care did not vary much over time, the mean DOS for hospice care changed significantly. Many Taiwanese cancer patients who could potentially benefit from hospice care do not receive it in time. Further research is warranted to investigate factors influencing hospice use and the timing of hospice referrals to facilitate appropriate use of hospice care for cancer patients in Taiwan.