Factors Related to Palliative Care Use in Patients With Hematologic Malignancies
No data exist on current trends and practice patterns for palliative care use among patients with cancer, particularly those with hematologic malignancies. Sikander Ailawadhi, MD, at the Mayo Clinic in Jacksonville, FL, discussed their findings on these trends at the ASH Annual Meeting.
Researchers used the 2016 National Cancer Database 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), and Hodgkin disease (n = 9,871) who were diagnosed between 2004 and 2013. Deceased patients who received palliative care as part of initial therapy (n = 15,352, 5.2%) for these diagnoses were stratified by survival duration (less than 6, 6–24, 24–60, and more than 60 months).
Compared to patients diagnosed between 2004 and 2005, patients diagnosed between 2012 and 2013 had significantly higher odds of palliative care use in those surviving more than six months (odds ratio [OR] = 1.28, 95% CI = 1.17–1.39) but not for those with longer survival.
Palliative care included surgery, radiation, or chemotherapy in 68% of patients; pain management only in 14.5%; both surgery, radiation, or chemotherapy and pain management in 5%; and the remaining 12.5% was an unknown modality.
Overall palliative care use decreased significantly as the duration of patient survival increased, from 7.2% in the less-than-six-months group to 2.9% in the more-than-60-months group (p < 0.001). Palliative care was used most often among patients with MM (OR = 2.65–59.56, reference = AML) and used least often for patients with CLL (OR = 0.51–2.94, reference = AML). Palliative care use increased significantly for the less-than-six-months and 6–24 months survival groups with increasing age (p < 0.001), but not for those with longer follow-up. Palliative care use did not differ by gender for any survival group. It did increase significantly for patients with higher Charlson Comorbidity Index scores, but only for those with less than six months’ survival (p < 0.001).
Palliative care use was significantly impacted based on race/ethnicity in those who survived less than six months, with less use among non-Hispanic blacks (OR = 0.90, 95% CI = 0.82–0.98) compared to non-Hispanic whites. Hispanics had an increased use of palliative care among those with more than 60 months’ survival (OR = 1.7; 95% CI, 1.09–2.63).
Palliative care use was not impacted by location of patient residence (urban or rural) or distance from the treating facility for any survival duration group. The only influence of geographic region was for patients with less than six months’ survival: palliative care utilization 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 (reference = East Coast).
Palliative care use was impacted by insurance status, but only for those surviving 6–24 months where patients with an “other government” payer were most likely to get palliative care (OR = 1.82, 95% CI = 1.32–2.5, reference = private insurance). Median patient income and palliative care use interacted significantly across survival groups (p = 0.011), but no clear trend was identified within any specific subgroup by income or survival category.
Higher palliative care use was noted with increasing literacy level (p < 0.001), but only in those with less than six months’ survival. Compared to nonacademic cancer programs, academic/research programs were less likely to use palliative care in those surviving 24–60 months (OR = 0.85, 95% CI = 0.76–0.94) and more than 60 months (OR = 0.74, 95% CI = 0.61–0.89), whereas no significant difference existed in those surviving less than six months (OR = 1.06; 95% CI, 1.00–1.12) or 6–24 months (OR = 1.0; 95% CI, 0.92–1.08).
“Despite national guidelines and near universal recommendations, overall utilization of palliative care was dismal and lesser so in academic cancer programs, including National Cancer Institute-designated centers,” the researchers concluded.