Chicago, IL—Early institution of palliative care in patients with lung cancer is not only humane, it is cost-effective, according to Craig C. Earle, MD, Director of the Health Services Research Program for Cancer Care Ontario and the Ontario Institute for Cancer Research, at a session on the cost of lung cancer care at ASCO 2012.
“The costs of cancer treatment near the end of life can be significant, both economically and in terms of patient and caregiver quality of life. What we do influences the cost of care, especially at the end of life. We need to appreciate the limits of benefit associated with aggressive treatment as the end of life nears and know the potential benefits of early institution of palliative care in this setting,” Dr Earle said.
The cost trajectory is a U-shaped curve, he noted. “The cost is high at the beginning, is less in the middle, and invariably rises rapidly at the end of life.” Palliative care, instituted at diagnosis when patients live 6 months, costs approximately $6000 per patient (mean reimbursement) in the first couple of months but then results in much lower monthly costs compared with chemotherapy. At month 6 (end of life), the mean reimbursement for palliative care is approximately $5000, whereas it climbs to $8000 when chemotherapy is delivered, Dr Earle said.
The trend toward aggressive care at the end of life has been increasing slowly during the past 15 years. Although this overuse became evident a decade ago, little has been done to curb its trajectory.
Evidence shows that aggressive use of chemotherapy near death is unrelated to the likelihood of better outcomes, yet there are many rationales for futile care: patients or families request it, it is seen as preserving hope, it is thought that doing something is better than doing nothing, it is easier for oncologists to give chemotherapy than withhold it, the occasional patient responds and has meaningful palliation after aggressive treatment, patients will accept more toxicity than oncologists think they will, and, in some cases, providers have financial incentives, he suggested.
“If oncologists don’t have support to give good palliation, then perhaps we continue to do what we were trained to do, give chemotherapy,” Dr Earle urged. “But if we as healthcare providers say we would not want aggressive treatment ourselves, perhaps because we have a true idea of the tradeoffs, then maybe we should be more paternal as we shepherd patients through the disease course.”
The Value of Palliative Care
Perceptions were changed, to some degree, by a couple of recent studies that confirmed that an aggressive approach continued to near-death does not improve outcomes and that early institution of symptomatic/palliative care does not adversely affect survival.
In a study led by Dr Earle, overall survival among elderly patients with lung cancer was better in patients who used a hospice versus those not in a hospice (25.7% vs 20.7%, respectively, at 1 year postdiagnosis, and 6.9% vs 5.5%, respectively, at 2 years; P <.001). There was no significant difference between those with shorter and those with longer duration hospice stays (Saito AM, et al. J Palliat Med. 2011; 14:929-939).
In another study (Temel JS, et al. N Engl J Med. 2010;363:733-742), early initiation of palliative care was associated with less aggressive treatment and a 3-month survival advantage, as well as greater patient and family satisfaction. Dr Earle noted that other studies have shown that patient and caregiver satisfaction is worse when chemotherapy is overused, when death occurs in the hospital or in the intensive care unit, and when patients are not admitted (or admitted only briefly) into a hospice. More aggressive care also has been associated with higher rates of depression among bereaved caregivers, he added.
Change Is Possible
As more emphasis is placed on avoiding futile chemotherapy, and as pathways are being developed to enforce this, the opposite trend is beginning to emerge, Dr Earle said. For example, with feedback from ASCO’s Quality Oncology Practice Initiative (QOPI), the use of chemotherapy in the last 2 weeks of life in one institution declined from 50% to 20% (Blayney DW, et al. J Clin Oncol. 2009;27:3802-3807). “Our practice changed toward the QOPI national practice norm after a presentation of the results at a faculty research conference,” the authors of this article wrote.