Sun Hyun Kim

Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients.

Limited data are available on how the timing and setting of palliative care (PC) referral can affect end‐of‐life care. In this retrospective cohort study, the authors examined how the timing and setting of PC referral were associated with the quality of end‐of‐life care.

Access to Palliative Care Among Patients Treated at a Comprehensive Cancer Center

BACKGROUND Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral. METHODS We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death. RESULTS In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5-4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6-45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC. CONCLUSIONS We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.

Clinical Response to an Outpatient Palliative Care Consultation in Patients With Advanced Cancer and Cancer Pain

CONTEXT There is limited published data regarding the outcomes of palliative care consult on cancer pain treatment at the first follow-up visit. OBJECTIVES The primary aim of this study was to determine pain treatment response to an outpatient palliative care consultation at the first follow-up visit for patients with cancer pain. METHODS Data from consecutive patients (n=1612) who were referred to the outpatient Supportive Care Center at The University of Texas M. D. Anderson Cancer Center and completed the Edmonton Symptom Assessment System at their initial and subsequent visits from January 2003 to December 2010 were reviewed. All patients received interdisciplinary care led by palliative care specialists following an institutional protocol. Pain treatment response was defined as a ≥2 point or ≥30% reduction from baseline. Using logistic regression models, predictive factors associated with pain treatment response were assessed. RESULTS The mean (SD) baseline pain was 5.36 (2.9). Of the 1612 patients, 462 (29%) rated their pain as mild (numeric rating scale [NRS] score 0-3), 511 (32%) as moderate (NRS score 4-6), and 639 (39%) as severe (NRS score 7-10). Almost half (728 of 1612 [45%]) of the patients achieved pain treatment response. However, 228 of 728 (31%) responding patients still had pain ≥4 at the first follow-up visit in 15 days on average. Of the 462 patients with mild pain at baseline, 147 (32%) had worse pain at the first follow-up visit. Factors associated with clinical response were baseline pain intensity (odds ratio [OR] per point 1.4; P<0.01), fatigue (OR per point 1.01; P=0.014), and Edmonton Symptom Assessment System symptom burden (OR per point 1.01; P=0.039). CONCLUSION More than half of the patients with moderate/severe pain were nonresponders, and about one-third of the patients with mild pain had an increase in pain severity to moderate/severe levels at the first follow-up. More frequent follow-up visits, phone calls, and interdisciplinary clinics may improve pain control.

Access to palliative care before death among patients treated at a comprehensive cancer center.

25 Background: Palliative care (PC) access is a critical component of quality cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually received PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center, and the predictors of PC referral. METHODS We reviewed the charts ofconsecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center and died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death using univariate and multivariate logistic regression. RESULTS A total of 366/816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range (0.5-4.2) and the median number of medical team encounters before PC was 20 (6-45). In multivariate analysis, older age, being married, and specific cancer types (gynecology, lung and head and neck) were significantly associated with a PC referral (Table). Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between advanced cancer diagnosis and PC consultation (median 16 months), the shortest interval between PC consultation and death (median 0.4 month), and one of the largest number of medical team encounters (median 38) before PC. CONCLUSIONS We found that a majority of cancer patients at our cancer center did not access PC before they die. PC referral occurs late in the disease process with many missed opportunities for referral. Further effort is needed to improve quality of end-of-life care. [Table: see text].

Targeted agent use in patients with cancer at the end of life.

215 Background: Chemotherapy use at the end of life is considered an indicator of poor quality of care. The use of targeted agent has not been well characterized. In this study, we determined the frequency and predictors of targeted therapy use in the last 30 days of life. METHODS All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents. RESULTS 816 patients were included: average age 62 (range 21 to 97), female 48% and White 61%. The median interval between the last treatment and death was 47 (interquartile range 21 to 97) days for targeted agents and 57 (26 to 118) days for chemotherapeutic agents. 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy within the last 30 days of life. 43 (5%) patients received targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n=25), bevacizumab (n=20) and rituximab (n=11). In multivariate analysis, younger age, hematologic, and lung malignancies were associated with increased targeted agent use in the last 30 days of life (Table). CONCLUSIONS Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed. [Table: see text].

Frequency and predictors of response to outpatient palliative care in patients with moderate to severe cancer pain.

e19698 Background: Pts with advanced cancer frequently suffer from uncontrolled pain. Response rate is an important clinical and quality of care outcome in most guidelines. The primary aim of this study is to determine frequency and predictors associated with pain response to state of the art palliative care. METHODS Consecutive pts with advanced cancer with moderate to severe pain presenting in the Supportive care clinic with a complete Edmonton symptom assessment scale (ESAS) at initial and subsequent visit were reviewed. All pts received interdisciplinary care led by palliative care specialists (IDT) following common care pathways. A logistic regression model to determine if baseline demographics, primary cancer type, ESAS, Memorial Delirium assessment scale, and CAGE (screening for alcoholism), were associated with response (defined as ≥2 points reduction in pain intensity). RESULTS 1150 pts (median age 60; male/female ratio 0.98) were included. Median time between initial and follow-up visit 15 days. The mean (SD), median baseline pain was 6.8 (1.9) and 7. Overall 598/1150 patients (52%) had a response. 411/639 (64%) of pts with pain ≥7/10 (severe pain group) at baseline had response compared to 187/511 (37%) of pts with moderate pain (4-6/10), (p<0.0001), however 217/639(34%) of the severe pain group had pain improved to ≤ 3/10 (mild pain) as compared to 170/511(33%) in moderate pain group (p=0.07). Fatigue (r=0.22, p<0.01), depression (r=0.14, <0.01), anxiety (r=0.16, p<0.01), sleep (r=0.15, p<0.01), and feeling of wellbeing (r=0.14, p<0.01), appetite (r=0.14, p<0.01), nausea (r=0.18, p<0.01) are associated with pain at initial consult. Factors associated with response to pain were baseline pain (OR, 1.4 per point; p<0.01), fatigue (OR, 1.01 per point; p=0.014) and ESAS symptom burden (OR, 1.01 per point; p=0.039). However, delirium (p=0.50), alcoholism (p=0.19), depression (p=0.35), anxiety (p=0.25), sleep (p=0.16) did not show significant association with pain response. CONCLUSIONS Current response criteria have more false positive results in severe pain group. Pts with severe pain needs more frequent and aggressive IDT. Further studies are warranted.