Two studies appearing in the journal Cancer confirmed that, despite efforts to promote palliative-only care for terminal patients, aggressive treatment remains common for those likely to die soon.
In one involving adults with a variety of solid cancers, Swedish researchers found that patients continued to receive treatment during the final year of life with drugs mainly intended for long-term prevention.
Receipt of such agents accounted for about 20% of the total cost of the drugs prescribed during the final stages of patients’ lives, the same study indicated. “The continuation of preventive drugs among older patients with advanced cancer has come under scrutiny because these drugs are unlikely to achieve their clinical benefit during the patients’ remaining lifespan,” Lucas Morin, MS, Karolinska Institute, Stockholm, and colleagues explained.
“Physicians should carefully consider whether the prescribed drugs are likely to achieve their benefit within the patient’s remaining lifetime,” the authors concluded. The study included 151,201 patients ages 65 years and older who died in Sweden at a mean age of 81.3 years from 2007 to 2013. “The use and cost of preventive drugs during the last 12 months of life were the main study outcomes,” investigators pointed out. The drugs of “questionable benefit” assessed in the current study included antidiabetic drugs, antihypertensives, statins, and bisphosphonates medications for the treatment of chronic anemia and vitamin and mineral supplements.
“Throughout the last year of life, the mean number of prescribed drugs increased from 6.9 to 10.1 (mean difference 2.1; 95% CI 2.0-2.2) and the percentage of individuals using ≥10 drugs rose from 26% to 52%,” researchers reported. For example, over 60% of patients received an antihypertensive during their last month of life.
But other drugs including antithrombotics, antianemics, lipid-lowering drugs, antidiabetic drugs, and mineral supplements were also commonly prescribed, Morin and colleagues pointed out. The prescription of various preventive drugs up until the final month of life varied depending on the drug but, for example, 56.6% of patients remained on a bisphosphonate until a month preceding their death while 65% of patients remained on a statin and vitamins.
Worse, at least 80% of patients remained on insulin, beta-blockers, and vitamin B12 or folic acid until their final month of life as well, researchers added. Importantly, as well, treatment with an antithrombotic agent was initiated in over 28% of patients during the final year of life, while antihypertensive therapy was initiated in almost one-quarter of the same cohort of patients. “The median drug cost during the last year of life was $1,482 (interquartile range $700-$2,896),” Morin and colleagues wrote.
However, drug costs were higher among patients with breast cancer, gynecological cancers, and cancers of the male genital organs as well as those with multiple solid tumors compared to patients who died with lung cancer. The authors acknowledged that initiation of some preventive medicines such as anticoagulants at the end of life are not necessarily inappropriate because they may be prescribed to avert serious complications such as deep vein thrombosis.
“However, the large percentage of older adults with cancer who continue to receive statins, antihypertensives, and vitamins and mineral supplements throughout the last year of life does suggest the existence of routine-based prescribing practices that contribute to low-value care,” Morin’s group stated. “The frequent continuation of long-term preventive drugs is indicative of insufficient deprescribing strategies at the end of life,” they concluded.
No different for children
Meanwhile, the use of aggressive care during the last 30 days of life among a largely pediatric population who died in French hospitals seemed to be exceedingly high, according to a population-based, retrospective study led by Laurent Boyer, MD, PhD, Aix-Marseille University in France, also published in Cancer. The study involved 1,899 patients 25 years of age and under who died of cancer in a French hospital during 2014-2016.
In the group overall, 61.4% received “high-intensity end-of-life” care within the last 30 days of life. This was defined as receipt of at least one chemotherapy session within the last 2 weeks of life; receiving ICU care at least once in the last 30 days of life; or at least one emergency room admission or hospitalization in an acute care unit.
Furthermore, 29% of the group were given what investigators termed the most invasive form of end-of-life care, which included use of intubation or ventilation or both, cardiopulmonary resuscitation, and hemodialysis during the last 30 days of life.
Moreover, patients living in socially disadvantaged areas were 30% more likely to receive intense end-of-life care (adjusted OR 1.30, 95% CI 1.03-1.65; P=0.028) and to visit emergency rooms. The same group of patients also had lower rates of access to palliative care services, Boyer and colleagues pointed out.
Patients with hematological malignancies were also over twice as likely to receive aggressive end-of-life treatment (adjusted OR 2.09, 95% CI 1.57-2.77; P<0.001). As the authors pointed out, hematological malignancies are often more amenable to cure than solid tumors.
“Therefore, transitioning from curative interventions to palliative care may be more difficult for patients, caregivers, and professionals,” they speculated. Patients who had complex chronic conditions as well as those who received care in a specialty center were also more likely to receive aggressive care (adjusted OR 1.60 and 1.70, respectively; P=0.001 for both).
In contrast, palliative care patients were 69% less likely to receive aggressive care than non-palliative care patients (adjusted OR 0.31, 95% CI 0.24-0.41; P<0.001), Boyer and colleagues emphasized. Palliative care patients were also less likely to receive the most intensive care, “confirming the positive impact of access to palliative care on treatment aggressiveness,” the authors emphasized.
Notably, Boyer and colleagues did not judge whether the high rates of intense end-of-life care were inappropriate. But they suggested that their “findings should draw the attention of health care workers and health decision makers and help them to implement specific, appropriate interventions to improve EOL care management.”
They also said the study underscores the importance of developing palliative care services for pediatric and young adult populations.
None of the authors in either study had any conflicts of interest to declare.
Primary Source
Cancer
Secondary Source
Cancer
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