Many older patients with acute myeloid leukemia (AML) do not receive hospice care, and many of those who enroll do so only days before death, according to a review of end-of-life (EOL) patterns in this patient population, which was published in the Journal of Clinical Oncology.
Rong Wang, PhD, of the Department of Chronic Disease Epidemiology at the Yale School of Public Health in New Haven, Connecticut, and co-authors found that, although the use of hospice care increased by approximately 80 percent in the last 20 years, it still is not optimal.
The investigators conducted a population-based, retrospective cohort analysis of the Surveillance, Epidemiology, and End Results-Medicare linked database to identify 13,156 patients with AML who were 66 years or older at diagnosis. Patients were included if they were diagnosed between 1999 and 2011, had died before December 31, 2012, had continuous Medicare fee-for-service coverage (Parts A and B), and were not enrolled in a health maintenance organization from 12 months before diagnosis through death.
The researchers analyzed Medicare claims for hospice care and use of treatments (including chemotherapy and transfusion) and assessed potential patient characteristics that may influence EOL care.
For the entire cohort, the median survival was 2.4 months (range = 1.12-7.16 months). During this time, 5,847 patients (44.4%) were enrolled in hospice and 5,816 (44.2%) received chemotherapy after an AML diagnosis. At the time of death, 43 percent (n=5,662) died in a hospital and 40.5 percent (n=5,322) died in hospice care.
While the proportion of patients with hospice enrollment increased continuously between 1999 and 2012 (from 31.3% to 56.4%), most of this increase was driven by late enrollment (within 7 days before death). Among those in hospice, 47.4 percent entered during the last seven days of life, and 28.8 percent entered during the last three days of life.
“The increased overall use of hospice with concomitant increase in the proportion admitted [to hospice] within seven days of death raises the question of whether patients are simply being admitted to hospice to manage death rather than obtain the benefits of symptom management and palliative support that hospice can provide,” the authors wrote.
The following patient factors were associated with greater likelihood of enrolling in hospice (p<0.01 for all):
- older age
- more comorbidities
- residence in regions other than the Northeast U.S. or metropolitan/urban areas
- death in more recent years
- longer survival
In addition, “patients who were older, resided in regions other than the Northeast U.S., or survived longer were less likely to have late enrollment,” the authors added. “Patients who died in more recent years were more likely to have late enrollment” (p<0.05 for all).
Also, while hospice enrollment increased during the study period, so did admission to the intensive care unit (ICU) within the last 30 days of life and receipt of chemotherapy in the last 14 days. Overall, 1,528 patients (11.6%) received chemotherapy within 14 days of death, and this number increased from 7.7 percent in 1999 to 18.8 percent in 2012.
However, receipt of chemotherapy late in life made patients less likely to enroll in hospice (22.1% vs. 47.4%; p<0.01). “The increased use of potentially aggressive treatments, especially chemotherapy, may be partly attributable to the introduction of less-toxic treatments such as the hypomethylating agents azacitidine and decitabine, which are often used off label to treat older patients with AML,” the authors noted.
Patients were more likely to receive chemotherapy in the last 14 days of life if they were male, married, or died in more recent years; those who were older, had state Medicaid buy-in, or did not reside in the Northeast U.S. or a metropolitan area were less likely to receive chemotherapy.
“There are no clear stopping rules for anti-cancer treatment,” the researchers continued. “Because novel therapies increasingly offer durable clinical responses in a small proportion of patients, improved predictive models and better communication strategies are needed to ensure patients understand the risks and benefits of a given therapy.”
A total of 3,956 patients (30.1%) were admitted to the ICU within 30 days of death, and ICU admitted-patients were less likely to enroll in hospice (26.7% vs. 52.1%; p<0.01). Patients receiving chemotherapy – except those with state Medicaid buy-in – were more likely to be admitted to the ICU within the last 30 days of life (43% vs. 28.4%; odds ratio = 1.19; 95% CI 1.05-1.33; p<0.01).
“We observed that patients with AML disenrolled from hospice and then received treatment outside of hospice, consisting most often of transfusion support rather than chemotherapy,” the authors reported. “The transfusion needs of patients with AML may constitute a barrier to timely hospice enrollment and prompt hospice disenrollment.”
“Changes to hospice services, such as enabling the provision of transfusion support, and improvements in physician-patient communications, may help facilitate better EOL care in this patient population,” the authors concluded.
The study is limited by its retrospective design and the inclusion of only Medicare beneficiaries – meaning the results may not be generalizable to the larger population of older patients with AML. The reliance on Medicare claims database information also limited conclusions about the appropriateness of chemotherapy at the end of life because the database did not distinguish chemotherapy given for palliative purposes.
The authors report no financial conflicts.
Wang R, Zeidan AM, Halene S, et al. Health care use by older adults with acute myeloid leukemia at the end of life. J Clin Oncol. 2017;35:3417-24.