Financial Disclosure. Learning Objectives. Evaluation of Chemotherapy in Last 2 Weeks of Life: CAMC Patterns of Care

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1 Evaluation of Chemotherapy in Last 2 Weeks of Life: CAMC Patterns of Care Steven J. Jubelirer, MD Clinical Professor Medicine WVU Charleston Division Senior Research Scientist CAMC Research Institute Charleston Area Medical Cancer Charleston, WV Financial Disclosure I have no relevant financial conflict of interest related to this presentation Learning Objectives Understand the basis for refraining from chemotherapy in the last 2 weeks of life To make people aware of the incidence of chemotherapy in the last 2 weeks Recognize the many factors related to chemotherapy given in the last 2 weeks of life To emphasize the importance of a Palliative Care Consult in those cases where the role of chemotherapy is in question

2 Background Evidence suggests that minimizing aggressive treatment for patients with terminal cancer may provide a better quality of life. (Temmel NEJM, 2010; Greer J. Clin Onc. 2012) The American Society of Clinical Oncology (ASCO) quality practice initiative (2011) established no chemotherapy within the last 2 weeks as a metric for quality end-of-life care. (ASCO, 2012 QOPI quality measures Background Analysis of Medicare patients yo diagnosed w/advanced cancer in 2010 (Dartmouth Atlas 2013): Category Nationwide West Virginia Death in Hospital 24.70% 33-47% Hospice Last Month of Life 63.40% 60.70% Chemo in Last 2 Weeks 6.20% 4.70% Goodman, David C., et al. Trends in cancer care near the end of life. A Dartmouth Atlas of Health Care Brief (2013).

3 Study Purpose The purpose of this study is to quantify the number of CAMC patients (> = 18 years of age) who received chemotherapy 2 weeks before death between 01/01/13-12/31/15 and to determine the factors that affected the use of chemotherapy in these 2 weeks Hypothesis Only a small percentage of CAMC patients will have received chemotherapy in the last 2 weeks of life Methods IRB-approved retrospective clinical study of adult patients diagnosed with cancer at CAMC who died between 01/01/ /31/2015 Patient data was obtained electronically from CAMC cancer registry as well as Soarian and Cerner chart review

4 Methods CAMC patients with cancer that expired were stratified into two cohorts dependent on whether the received or did not receive chemotherapy within the last 2 weeks of life Statistical Analysis Statistical analysis was performed using SAS 9.3 Analysis was performed using chi square and Fischer exact test for categorical data Population Demographics All Patients % (n = 1,302) Sex Male 52% (682) Female 48% (620) Age < 65 39% (505) 65 61% (797) Mean (SD) 68 ± 13(range ) Ethnicity Caucasian 1241 (95) Married 443 (53)

5 Cancer Type Hematological 13% (n= 166) Solid 87% (n = 1136) Solid Hematological Patient Comorbidities Pulmonary Disease 56% Diabetes 37 % Coronary artery disease - 36% Congestive heart failure 22% Liver disease 11% Peripheral vascular disease 10% Dementia 9% Chemotherapy in the Last 2 Weeks of Life 5% Chemotherapy (n = 70) 95% No Chemotherapy (n = 1232) Chemotherapy in the last 2 weeks No chemotherapy in the last 2 weeks

6 Factors Associated with Chemotherapy in the Last 2 Weeks of Life Variable Age No chemo Yes chemo < Race White 96 4 Other 97 3 Marital Status Married 94 6 Not married 95 5 P value Factors Associated with Chemotherapy in the Last 2 Weeks of Life Variable Sex No chemo Yes chemo Male 95% (648) 5% (34) Female 94% (584) 6% (36) P value.51 Factors Associated with Chemotherapy in the Last 2 Weeks of Life Variable No chemo Yes chemo Tumor Type Hematological 95 5 Solid 95 5 Location at Death (not know for all patients) Inpatient Home, hospice, 96 4 Progression of cancer with metastasis or relapse Yes No 93 7 P value

7 Factors Associated with Chemotherapy in the Last 2 Weeks of Life Variable No chemo Yes chemo P value Pulmonary Disease Diabetes Coronary artery disease Liver Disease Peripheral vascular disease CHF Dementia Palliative Care Consultations No Palliative Consult 67.8% (n=836) Palliative Consult 32.2% (n=466) Palliative Care Consult No Palliative Care Consult Number of Palliative Care Consultations No consultations 67.8% Palliative Care consultations 32.2% (n = 466) One consultations 90% (n= 419) Two consultations 8.8% (n= 41) Three or more consultations 1.2% (n = 6)

8 Factors Associated with Chemotherapy in Last 2 Weeks of Life Variable No chemo Yes chemo Palliative Care Consult Yes 94 (438) 6 (28) No 95 (794) 5 (42) P value.42 The Influence of the Number of Palliative Care Consults on the Use Chemotherapy Palliative Care Consults Percent receiving Chemotherapy in last 2 weeks 0 consults 5% 1 consult 6% 2 consults 2.4% > = 3 consults 0% Comparison to Other Studies Age 18 Study % receiving Chemotherapy in the last 2 Jubelirer This study (n = 1,302) 5.00 p value compared to CAMC study Kao (2009) (n = 747) Mack (2012) (n= 1231) 16.0 <.001 Choi (2012) (n = 263) 23.0 <.001 Rodriguez (2014) (n = 7399) Dudevich (2014) (n = 24780) 2.00 <.001 Adam (2014) (n = 119) Wright (2014) (n = 386)

9 Comparison to Other Studies Study Jubelirer This study (n = 763) Goodman (2013) (n = ) Age years % receiving Chemotherapy in the last p value compared to CAMC study.052 Jubelirer This study (n = 797) Earle (2004) (n = 28777) > = Conclusions Both ASCO and NCCN recommend that chemotherapy should be not given in the last 2 weeks of life CAMC is in step or ahead of other major medical centers with regards to the percentage of patients receiving chemotherapy in the last 2 weeks of life Lowest rate (2%) was observed by Dudevich (2014) (Canada) Highest rate (23%) reported by Choi (2012) (South Korea) Conclusions Factors associated with increase palliative care in the last 2 weeks of life were age 65 and those who were hospitalized at the time of death This study indicates that there is a trend for decreased chemotherapy in the last 2 weeks with increasing palliative care consults This finding emphasizes the need to refer patient to palliative care Clinicians must have an open dialogue with patients and family members with regard to chemotherapy use at the end-of-life and help them understand the positive aspects of quality at the end-oflife

10 Discussion In order to reduce late chemotherapy administration, improved communication between the oncologist and the patient and his/her family is necessary (JHU Editorial) Oncologists must elucidate the prognosis in clear terms despite the difficulty of end-of-life discussions and fear of compromising the physician-patient relationship The use of conversational scripts and close integrate with palliative care providers can ease the emotional burden of end-of-life discussions Early and close palliative care integration can provide early hospice referrals and thus decrease symptom distress and improve overall end-oflife quality for the patient Limitations Retrospective study design Missing data Small sample size Limited documentation of physician-patient conversations influencing patients decisions to take on chemotherapy Performance status not documented in most patients ECOG/KPS Performance Status JAMA Oncol. 2015;1(7):998. doi: /jamaoncol

11 References Adam H. et al. Chemotherapy near the end of life: a retrospective single-centre analysis of patients charts. BMC palliative care 2014, 13:26. Choi Y. et al. Cancer Treatment near the end-of-life becomes more aggressive: changes in trend during 10 years at a single institute. Cancer Res Treat 2015;47(4): Dudevich A. et al. End-of-life hospital care for cancer patients: an update. CIHI Survey. Healthcare Quarterly 2014; 17(3):8-10. Earle, Craig C., et al. "Trends in the aggressiveness of cancer care near the end of life." Journal of Clinical Oncology 22.2 (2004): Goodman, David C., et al. Trends in cancer care near the end of life. A Dartmouth Atlas of Health Care Brief (2013). Kao, S. et al. Use of chemotherapy at end of life in oncology patients. Annals of Oncology 20.9 (2009): Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: Predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol Mar 1;28(7): Rodriguez, Maria et al. Use of Chemotherapy Within the Last 14 Days of Life in Patients Treated at a Comprehensive Cancer Cancer. JAMA Intern Med. 2014; 174 (6): doi: /jamainternmed Temel, Jennifer S. et al. Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine (2010): Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, Schrag D. Patients expectations about effects of chemotherapy for advanced cancer. N Engl J Med Oct 25;367(17): Wright AA. Association between palliative chemotherapy and adult cancer patients end of life care and place of death: prospective cohort study. BMJ 2014;348:g1219 Thank you Questions?