Palliative Care Use Infrequent in Patients with Hematologic Malignancies

Use of palliative care services among patients with hematologic malignancies is “sporadic at best,” and there was no clear subgroup receiving uniform care, according to a review of patterns in use among nearly 300,000 patients.

There are limited data on trends and practice patterns for palliative care use among patients with hematologic malignancies, but this study represents the largest-ever analysis of palliative care trends, noted lead author Sikander Ailawadhi, MD, of the Division of Hematology-Oncology at the Mayo Clinic in Jacksonville, Florida. Dr. Ailawahdi presented the findings at the 2017 ASH Annual Meeting.

However, there were few trends to report: “We noted significant heterogeneity in practice patterns by all characteristics studied, underscoring the need for standardized implementation with public, health-care provider, institutional, and political will,” the authors noted.

To define potential patterns in palliative care use among this patient population, the researchers used the 2016 National Cancer Database (NCDB) to identify 293,518 patients with non-Hodgkin lymphoma (n=147,614), multiple myeloma (MM; n=59,572), chronic lymphocytic leukemia (CLL; n=20,634), acute myeloid leukemia (AML; n=55,827), or Hodgkin lymphoma (n=9,871) who were diagnosed between 2004 and 2013.

Patients who had died during the study period but who received palliative care as part of initial therapy (n=15,352; 5.2%) for these diagnoses were stratified by survival duration: less than six, six to 24, 24 to 60, and >60 months.

Palliative care services used by enrolled patients included surgery, radiation, or chemotherapy in 68 percent of patients; pain management only in 14.5 percent; pain management and surgery, radiation, or chemotherapy in 5 percent; and the remaining 12.5 percent was delivered through an unknown modality.

Use of palliative care was significantly associated with length of survival. Overall palliative care use decreased as survival duration increased, from 7.2 percent in the those with less than six months survival to 2.9 percent in those with >60 months (p<0.001).

Compared with patients diagnosed between 2004 and 2005, those diagnosed between 2012 and 2013 had significantly higher odds of palliative care use when survival was less than six months (odds ratio [OR] = 1.28; 95% CI 1.17-1.39; p value not provided); this trend was not observed among patients with longer survival, though.

Palliative care was used most often among patients with MM (OR=2.65-59.56; reference = AML) and used least among those with CLL (OR=0.51-2.94; reference = AML).

Palliative care use did not appear to be affected by sex, location of residence, or distance from the treating facility for any survival groups. The only geographic influence appeared in patients with less than six-month survival. In that group, palliative care use was higher in Mountain (OR=1.44; 95% CI 1.27-1.64) and Pacific (OR=1.19; 95% CI 1.09-1.32) regions, compared with those on the east coast.

The researchers identified several other factors associated with greater likelihood of receiving palliative care in certain survival groups, including:

  • increasing age (p<0.001; only in people with <6-month survival and 6- to 24-month survival)
  • heavier symptom burden, measured by Charlson Comorbidity Index score (p<0.001; only in people with <6-month survival)
  • higher literacy level (p<0.001; only in people with <6-month survival)
  • higher median patient income (p=0.011; no clear trend according to survival category)

Race/ethnicity also affected use of palliative care, but only among those who survived less than six months, with less use among non-Hispanic African Americans (OR=0.90; 95% CI 0.82-0.98; p value not reported), compared with non-Hispanic whites. However, Hispanics had an increased use of palliative care among those with longer than 60-month survival (OR=1.7; 95% CI 1.09-2.63; p value not reported).

Insurance status only affected rates of palliative care use in those surviving six to 24 months. Compared with those with private insurance, patients with “other government” payer insurance were more likely to receive palliative care (OR=1.82; 95% CI 1.32-2.50; p value not reported).

In a surprising finding, compared with treatment at a non-academic cancer program, treatment at an academic/research program was associated with lower likelihood of palliative care use, in both those surviving 24 to 60 months (OR=0.85; 95% CI 0.76-0.94; p value not reported) and more than 60 months (OR=0.74; 95% CI 0.61-0.89; p value not reported). Again, though, there were no clear relationships across survival categories, with little difference in those surviving less than six months (OR=1.06; 95% CI 1.00-1.12; p value not reported) or six to 24 months (OR=1.0; 95% CI 0.92-1.08; p value not reported).

“Despite national guidelines and near-universal recommendations, overall [use] of palliative care was dismal and lesser so in academic cancer programs, including National Cancer Institute–designated centers,” the researchers concluded.

Though this was a large study, the findings were potentially limited by the variability in data collected through the NCDB.

The authors report financial relationships with Novartis, Pharmacyclics, Amgen, and Takeda.


Reference

Ailawadhi S, Frank RD, Chimato NT, et al. Utilization of palliative care among patients with hematologic malignancies: an extensive national analysis to define trends and patterns. Abstract #2107. Presented at the 2017 American Society of Hematology Annual Meeting, Atlanta, GA, December 9, 2017.

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