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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Tsang M, LeBlanc TW. Palliative and End-of-Life Care in Hematologic Malignancies: Progress and Opportunities. JCO Oncol Pract 2024; 20:739-741. [PMID: 38478797 DOI: 10.1200/op.24.00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/13/2024] [Indexed: 06/14/2024] Open
Abstract
@JCOOP_ASCO editorial on unique needs of end-of-life care for different blood cancers discusses: #pallheme improves QOL but less utilized in cancers. Contextualize Weisse et al study. More #pallheme research needed for lymphoma and myeloma in era of cell therapy.
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Oluwole OO, Ray MD, Zur RM, Ferrufino CP, Doble B, Patel AR, Bilir SP. Cost-effectiveness of treating relapsed or refractory 3L+ follicular lymphoma with axicabtagene ciloleucel vs mosunetuzumab in the United States. Front Immunol 2024; 15:1393939. [PMID: 38855109 PMCID: PMC11157123 DOI: 10.3389/fimmu.2024.1393939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Novel therapies for 3L+ relapsed/refractory (r/r) follicular lymphoma (FL) have been approved recently by the US Food and Drug Administration including anti-CD19 CAR-T therapies such as axicabtagene ciloleucel (axi-cel) and CD20 × CD3 T-cell-engaging bispecific monoclonal antibodies such as mosunetuzumab (mosun). The objective of this study was to assess the cost-effectiveness of axi-cel compared to mosun in 3L+ r/r FL patients from a US third-party payer perspective. Methods A three-state (progression-free, progressed disease, and death) partitioned-survival model was used to compare two treatments over a lifetime horizon in a hypothetical cohort of US adults (age ≥18) receiving 3L+ treatment for r/r FL. ZUMA-5 and GO29781 trial data were used to inform progression-free survival (PFS) and overall survival (OS). Mosun survival was modeled via hazard ratios (HRs) applied to axi-cel survival curves. The PFS HR value was estimated via a matching-adjusted indirect comparison (MAIC) based on mosun pseudo-individual patient data and adjusted axi-cel data to account for trial populations differences. One-way sensitivity analysis (OWSA) and probabilistic sensitivity analyses (PSA) were conducted. Scenario analyses included: 1) the mosun HRs were applied to the weighted (adjusted) ZUMA-5 24-month data to most exactly reflect the MAIC, 2) mosun HR values were applied to axi-cel 48-month follow-up data, and 3) recent axi-cel health state utility values in diffuse large B-cell lymphoma patients. Results The analysis estimated increases of 1.82 LY and 1.89 QALY for axi-cel compared to mosun. PFS for axi-cel patients was 6.42 LY vs. 1.60 LY for mosun. Increase of $257,113 in the progression-free state was driven by one-time axi-cel treatment costs. Total incremental costs for axi-cel were $204,377, resulting in an ICER of $108,307/QALY gained. The OWSA led to ICERs ranging from $240,255 to $75,624, with all but two parameters falling below $150,000/QALY. In the PSA, axi-cel had an 64% probability of being cost-effective across 5,000 iterations using a $150,000 willingness-to-pay threshold. Scenarios one and two resulted in ICERs of $105,353 and $102,695, respectively. Discussion This study finds that axi-cel is cost-effective compared to mosun at the commonly cited $150,000/QALY US willingness-to-pay threshold, with robust results across a range of sensitivity analyses accounting for parameter uncertainty.
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MESH Headings
- Humans
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/economics
- Lymphoma, Follicular/mortality
- Cost-Benefit Analysis
- United States
- Biological Products/therapeutic use
- Biological Products/economics
- Male
- Antibodies, Bispecific/therapeutic use
- Antibodies, Bispecific/economics
- Female
- Immunotherapy, Adoptive/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Middle Aged
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Immunological/economics
- Adult
- Quality-Adjusted Life Years
- Neoplasm Recurrence, Local/drug therapy
- Aged
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Affiliation(s)
| | | | | | | | - Brett Doble
- Kite, A Gilead Company, Santa Monica, CA, United States
| | - Anik R. Patel
- Kite, A Gilead Company, Santa Monica, CA, United States
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Oluwole OO, Ray MD, Rosettie KL, Ball G, Jacob J, Bilir SP, Patel AR, Jacobson CA. Cost-Effectiveness of Axicabtagene Ciloleucel for Adult Patients With Relapsed or Refractory Follicular Lymphoma in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02334-9. [PMID: 38641058 DOI: 10.1016/j.jval.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/25/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES The results of a recent single-arm trial (ZUMA-5) of axicabtagene ciloleucel (axi-cel) for relapsed/refractory (r/r) follicular lymphoma (FL) demonstrated high rates of durable response and tolerable toxicity among treated patients. To quantify the value of axi-cel compared with standard of care (SOC) to manage r/r FL patients who have had at least 2 prior lines of systemic therapy (3L+), a cost-effectiveness model was developed from a US third-party payer perspective. METHODS A 3-state partitioned-survival cost-effectiveness model was developed with a lifetime horizon. Patient-level analyses of the 36-month ZUMA-5 (axi-cel) and SCHOLAR-5 (SOC) studies were used to extrapolate progression-free and overall survivals. After 5 years of survival, an estimated 40% of the modeled population was assumed to experience long-term remission based on literature. Results include the incremental cost-effectiveness ratio (ICER) measured as incremental cost per quality-adjusted life year (QALY) gained. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analyses were performed. All outcomes were discounted 3% per year. RESULTS Axi-cel led to an increase of 4.28 life-years, 3.64 QALYs, and a total cost increase of $321 192 relative to SOC, resulting in an ICER of $88 300 per QALY. Across all parameters varied in the one-way sensitivity analysis, the ICER varied between $133 030 and $67 277. In the probabilistic sensitivity analysis, axi-cel had a 99% probability of being cost-effective across 5000 iterations using a $150 000 willingness-to-pay threshold. CONCLUSIONS Given the robustness of the model results and sensitivity analyses, axi-cel is expected to be a cost-effective treatment in 3L+ r/r FL.
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Affiliation(s)
- Olalekan O Oluwole
- Vanderbilt University Medical Center, School of Medicine, Nashville, TN, USA.
| | | | | | - Graeme Ball
- Kite, A Gilead Company, Santa Monica, CA, USA
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Kim A, O'Callaghan A, Hemmaway C, Johney L, Ho J. Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre. Intern Med J 2024; 54:588-595. [PMID: 37718574 DOI: 10.1111/imj.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. AIMS This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. METHODS One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. RESULTS During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. CONCLUSIONS The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.
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Affiliation(s)
- Ann Kim
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Anne O'Callaghan
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Claire Hemmaway
- Clinical Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Leslie Johney
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Jess Ho
- School of Medicine, The University of Auckland, Auckland, New Zealand
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Knight HP, Brennan C, Hurley SL, Tidswell AJ, Aldridge MD, Johnson KS, Banach E, Tulsky JA, Abel GA, Odejide OO. Perspectives on Transfusions for Hospice Patients With Blood Cancers: A Survey of Hospice Providers. J Pain Symptom Manage 2024; 67:1-9. [PMID: 37777022 PMCID: PMC10873003 DOI: 10.1016/j.jpainsymman.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023]
Abstract
CONTEXT Patients with blood cancers have low rates of hospice use. While lack of transfusion access in hospice is posited to substantially contribute to these low rates, little is known about the perspectives of hospice providers regarding transfusion access in hospice. OBJECTIVES To characterize hospice providers' perspectives regarding care for patients with blood cancers and transfusions in the hospice setting. METHODS In 2022, we conducted a cross-sectional survey of a sample of hospices in the United States regarding their experience caring for patients with blood cancers, perceived barriers to hospice use, and interventions to increase enrollment. RESULTS We received 113 completed surveys (response rate = 23.5%). Of the cohort, 2.7% reported that their agency always offers transfusions, 40.7% reported sometimes offering transfusions, and 54.9% reported never offering transfusions. In multivariable analyses, factors associated with offering transfusions included nonprofit ownership (OR 5.93, 95% CI, 2.2-15.2) and daily census >50 patients (OR 3.06, 95% CI, 1.19-7.87). Most respondents (76.6%) identified lack of transfusion access in hospice as a barrier to hospice enrollment for blood cancer patients. The top intervention considered as "very helpful" for increasing enrollment was additional reimbursement for transfusions (72.1%). CONCLUSION In this national sample of hospices, access to palliative transfusions was severely limited and was considered a significant barrier to hospice use for blood cancer patients. Moreover, hospices felt increased reimbursement for transfusions would be an important intervention. These data suggest that hospice providers are supportive of increasing transfusion access and highlight the critical need for innovative hospice payment models to improve end-of-life care for patients with blood cancers.
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Affiliation(s)
- Helen P Knight
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Caitlin Brennan
- Care Dimensions Inc. (C.B., S.L.H.), Boston, Massachusetts; Boston College Connell School of Nursing (C.B.), Chestnut Hill, Massachusetts
| | | | - Anna J Tidswell
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine (M.D.A.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kimberly S Johnson
- Division of Geriatrics (K.S.J.), Duke University Medical Center, Durham, North Carolina
| | - Edo Banach
- Manatt Health (E.B.), Washington, District of Columbia
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A Abel
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Oreofe O Odejide
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts.
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Odejide OO, Aldridge MD. Access to High-Quality Hospice Care in a For-Profit World. Oncologist 2023; 28:743-745. [PMID: 37487057 PMCID: PMC10485296 DOI: 10.1093/oncolo/oyad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Evidence supporting the relief of suffering and improved end-of-life care provided by hospice is in contrast with recent media reports of cases of poor-quality care driven by profit-motivated hospices. This commentary presents a brief history of hospice and potential solutions to address the current challenges affecting access to high-quality hospice care.
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Affiliation(s)
- Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, NYUSA
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Jackson I, Etuk A, Jackson N. Prevalence and Predictors of Palliative Care Utilization among Hospitalized Patients with Diffuse Large B-Cell Lymphoma. J Palliat Care 2023; 38:167-174. [PMID: 35006019 DOI: 10.1177/08258597211073226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Research has shown that palliative care improves the quality of life of cancer patients; however, there is no literature on specific factors that predict its use in diffuse large b-cell lymphoma (DLBCL) patients. Therefore, the prevalence of palliative care utilization and predictors of palliative care utilization among patients with DLBCL were examined. Methods: Data from the National Inpatient Sample (NIS) collected between 2016 to 2018 were used for all analyses. Multivariable logistic regression models were used to examine the predictors of palliative care utilization among hospitalized patients with DLBCL. Descriptive analyses were used to explore the overall prevalence of palliative care receipt in this population. Results: Of the 41,789 hospitalizations, 7.1% of patients used palliative care during hospitalization, while 4.8% utilized palliative care and were discharged alive. DLBCL patients aged 70 and older had 1.3 times (95% CI: 1.14-1.41) higher odds of utilizing palliative care compared to those less than 70 years. Relative to Medicare/Medicaid patients, those with other types of insurance were 1.7 times (95% CI: 1.34-2.05) more likely to receive palliative care. Those who were either transferred to a facility/discharged with home health (AOR: 6.23; 95% CI: 5.21-7.44) or died during hospitalization (AOR: 45.17; 95% CI: 36.98-55.17) had higher odds of receiving palliative care when relative to those with a routine hospital discharge. Other associated factors were type of admission, length of stay, chemotherapy receipt, and number of comorbidities. Conclusions: The prevalence of palliative care utilization was low and factors predicting utilization in our population were identified. Our findings highlight the need to increase awareness among medical oncologists on the need to involve the palliative care team early in the management of hospitalized patients with DLBCL.
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Affiliation(s)
| | - Aniekeme Etuk
- University of Texas School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nsikak Jackson
- University of Texas School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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Kayastha N, LeBlanc TW. Palliative care for patients with hematologic malignancies: are we meeting patients' needs early enough? Expert Rev Hematol 2022; 15:813-820. [PMID: 36062508 DOI: 10.1080/17474086.2022.2121696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Palliative care for patients with cancer, and more recently for patients with hematologic malignancies, has increasingly been shown to be beneficial, with mounting evidence pointing to its vast benefits both to patients and caregivers. Despite this, there is a significant gap in integration of palliative care into usual cancer care for patients with hematologic malignancies. AREAS COVERED In this paper, we will define palliative care and discuss its benefits broadly for patients with hematologic malignancies. We will then discuss the late access to palliative care, the unmet needs in this patient population, and some of the barriers to access to palliative care. EXPERT OPINION With all this information and the clear benefit for early integrated palliative care for patients with hematologic malignancies, there is a need for novel models of palliative care and cancer care integration. Given the various needs of patients with different hematologic malignancies, we propose how palliative care can meet the unique needs of patients with hematologic malignancy by disease subtype.
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Affiliation(s)
- Neha Kayastha
- Department of Medicine, Duke University School of Medicine
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine.,Duke Cancer Institute
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Vaughn DM, Johnson PC, Jagielo AD, Topping CEW, Reynolds MJ, Kavanaugh AR, Webb JA, Fathi AT, Hobbs G, Brunner A, O'Connor N, Luger S, Bhatnagar B, LeBlanc TW, El-Jawahri A. Factors Associated with Health Care Utilization at the End of Life for Patients with Acute Myeloid Leukemia. J Palliat Med 2021; 25:749-756. [PMID: 34861118 DOI: 10.1089/jpm.2021.0249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Patients (≥60 years) with acute myeloid leukemia (AML) often receive intense health care utilization at the end of life (EOL). However, factors associated with their health care use at the EOL are unknown. Methods: We conducted a secondary analysis of 168 deceased patients with AML within the United States. We assessed quality of life (QOL) (Functional-Assessment-Cancer-Therapy-Leukemia), and psychological distress (Hospital-Anxiety-and-Depression Scale [HADS]; Patient-Health-Questionnaire-9 [PHQ-9]) at diagnosis. We used multivariable logistic regression models to examine the association between patient-reported factors and the following outcomes: (1) hospitalizations in the last 7 days of life, (2) receipt of chemotherapy in the last 30 days of life, and (3) hospice utilization. Results: About 66.7% (110/165) were hospitalized in the last 7 days of life, 51.8% (71/137) received chemotherapy in the last 30 days of life, and 40.7% (70/168) utilized hospice. In multivariable models, higher education (odds ratio [OR] = 1.54, p = 0.006) and elevated baseline depression symptoms (PHQ-9: OR = 1.09, p = 0.028) were associated with higher odds of hospitalization in the last seven days of life, while higher baseline QOL (OR = 0.98, p = 0.009) was associated with lower odds of hospitalization at the EOL. Higher baseline depression symptoms were associated with receipt of chemotherapy at the EOL (HADS-Depression: OR = 1.10, p = 0.042). Higher education was associated with lower hospice utilization (OR = 0.356, p = 0.024). Conclusions: Patients with AML who are more educated, with higher baseline depression symptoms and lower QOL, were more likely to experience high health care utilization at the EOL. These populations may benefit from interventions to optimize the quality of their EOL care.
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Affiliation(s)
- Dagny M Vaughn
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Connor Johnson
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Annemarie D Jagielo
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carlisle E W Topping
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Reynolds
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alison R Kavanaugh
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Webb
- Department of Medicine, Division of Hematology/Medical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - Amir T Fathi
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Brunner
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nina O'Connor
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Selina Luger
- Department of Medicine, Division of Hematology and Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bhavana Bhatnagar
- Department of Medicine, Section of Hematology/Oncology, West Virginia University Cancer Institute, Wheeling Hospital, Wheeling, West Virginia, USA
| | - Thomas W LeBlanc
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, USA
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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11
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Johnson PC, Markovitz NH, Yi A, Newcomb RA, Amonoo HL, Nelson AM, Reynolds MJ, Rice J, Lavoie MW, Odejide OO, Nipp RD, El-Jawahri A. End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma. J Palliat Med 2021; 25:728-733. [PMID: 34724798 PMCID: PMC9360173 DOI: 10.1089/jpm.2021.0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking. Methods: We conducted a retrospective analysis of adults ≥65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from April 2000 to July 2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the medical record. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization. Results: Among 91 patients (median age = 75 years; 37.4% female), 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. More than half of patients (51.6%, 47/91) died in a hospital or health care facility. In multivariable analysis, elevated lactic acid dehydrogenase was associated with risk of hospitalization within 30 days of death (odds ratio [OR] 3.61, p = 0.014). Palliative care consultation (OR 4.45, p = 0.005) was associated with a greater likelihood of hospice utilization, whereas hypoalbuminemia (OR 0.29, p = 0.026) was associated with a lower likelihood of hospice utilization. Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population.
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Affiliation(s)
- P Connor Johnson
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Netana H Markovitz
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alisha Yi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Richard A Newcomb
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ashley M Nelson
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Reynolds
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Rice
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitchell W Lavoie
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Oreofe O Odejide
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Center for Lymphoma, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Jackson I, Jackson N, Etuk A. Trends, Sociodemographic and Hospital-Level Factors Associated With Palliative Care Utilization Among Multiple Myeloma Patients Using the National Inpatient Sample (2016-2018). Am J Hosp Palliat Care 2021; 39:888-894. [PMID: 34663083 DOI: 10.1177/10499091211051667] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on multiple myeloma (MM) specific factors. MM patients have a high symptom burden and early involvement of palliative could increase their quality of life. We examined factors associated with palliative care utilization among MM patients and explored prevalence trends in palliative care utilization among patients with MM. METHODS Cross-sectional analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore prevalence trends in palliative care utilization over time. Multivariable logistic regression models were used to examine sociodemographic and hospital-level factors associated with palliative care utilization in MM patients. RESULTS Overall prevalence of palliative care utilization in our population was 7.7% with a trend of increasing use of palliative care from 7.3% in 2016 to 8.2% in 2018. MM patients aged 70 years and above had 1.30 times higher odds (95% CI: 1.20-1.42) of receiving palliative care relative to those younger than 70 years. Compared to non-Hispanic whites, non-Hispanic blacks (Adjusted odds ratio (AOR): 0.86; 95% CI: 0.79-0.94) were less likely to utilize palliative care. Patients on Medicaid (AOR: 1.27; 95% CI: 1.08-1.49), private insurance (AOR: 1.27; 95% CI: 1.16-1.39) and other insurance types (AOR: 2.10; 95% CI: 1.79-2.47) had significantly higher odds of receiving palliative care when compared to those on Medicare. Other factors identified were hospital region, location, patient disposition, admission type, length of stay, and number of comorbidities. CONCLUSION Our findings highlight the urgent need for education of hospital physicians on the need for early palliative care involvement in the care of hospitalized MM patients. Messaging interventions such as the delivery of pop-up messages in electronic medical records to serve as reminders for physicians can be explored as a potential way to increase palliative care consultations for patients who need them.
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Affiliation(s)
- Inimfon Jackson
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Nsikak Jackson
- Department of Management, Policy and Community Health, University of Texas School of Public Health, University of Texas Health Science Center at Houston, TX, USA
| | - Aniekeme Etuk
- Department of Management, Policy and Community Health, University of Texas School of Public Health, University of Texas Health Science Center at Houston, TX, USA
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13
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Lam MB, Riley KE, Zheng J, Orav EJ, Jha AK, Burke LG. Healthy days at home: A population-based quality measure for cancer patients at the end of life. Cancer 2021; 127:4249-4257. [PMID: 34374429 DOI: 10.1002/cncr.33817] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/01/2021] [Accepted: 06/30/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored. METHODS Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates. RESULTS The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH. CONCLUSIONS HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kristen E Riley
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K Jha
- Brown School of Public Health, Providence, Rhode Island
| | - Laura G Burke
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Hospital, Boston, Massachusetts
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14
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End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies. Blood Adv 2021; 4:3606-3614. [PMID: 32766855 DOI: 10.1182/bloodadvances.2020001767] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results-Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.
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15
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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16
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Al-Mondhiry JH, Burkenroad AD, Zhang E, Pietras CJ, Mehta AK. Needs assessment of current palliative care education in U.S. hematology/oncology fellowship programs. Support Care Cancer 2021; 29:4285-4293. [PMID: 33411046 DOI: 10.1007/s00520-020-05919-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Palliative care (PC) education for fellows in hematology/oncology (H/O) training programs is widely accepted, but no studies to date have assessed PC education practices and values among program leadership. METHODS Program Directors and Associate Program Directors of active H/O fellowship programs in the U.S.A. were surveyed. RESULTS Of 149 programs contacted, 84 completed the survey (56% response rate), of which 100% offered some form of PC education. The most frequently utilized methods of PC education were didactic lectures/conferences (93%), required PC rotations (68%), and simulation/role-playing (42%). Required PC rotations were ranked highest, and formal didactic seminars/conferences were ranked fifth in terms of perceived effectiveness. The majority felt either somewhat (60%) or extremely satisfied (30%) with the PC education at their program. Among specific PC domains, communication ranked highest, addressing spiritual distress ranked lowest, and care for the imminently dying ranked second lowest in importance and competency. Solid tumor oncologists reported more personal comfort with pain management (p = 0.042), non-pain symptom management (p = 0.014), ethical/legal issues (p = 0.029), reported their fellows were less competent in pain assessment/management (p = 0.006), and communication (p = 0.011), and were more satisfied with their program's PC education (p = 0.035) as compared with hematologists. CONCLUSIONS Significant disparities exist between those modalities rated most effective for PC education and those currently in use. Clinical orientation of program leadership can affect both personal comfort with PC skills and estimations of PC curriculum effectiveness and fellows' competency. H/O fellowship programs would benefit from greater standardization and prioritization of active PC education modalities and content.
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Affiliation(s)
- Jafar H Al-Mondhiry
- Division of Hematology & Oncology, Department of Medicine, University of California, Los Angeles, Box 951678 Factor Building, Los Angeles, CA, 90095-1678, USA.
| | - Aaron D Burkenroad
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Eric Zhang
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Christopher J Pietras
- Palliative Care Program, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, 21224, USA
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17
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Di M, Huntington SF, Olszewski AJ. Challenges and Opportunities in the Management of Diffuse Large B-Cell Lymphoma in Older Patients. Oncologist 2020; 26:120-132. [PMID: 33230948 DOI: 10.1002/onco.13610] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) are diagnosed at age 60 years or older. Challenges to effective therapy among older individuals include unfavorable biologic features of DLBCL, geriatric vulnerabilities, suboptimal treatment selection, and toxicities of cytotoxic chemotherapy. Wider application of geriatric assessments may help identify fit older patients who benefit from standard immunochemotherapy without unnecessary dose reductions. Conversely, attenuated regimens may provide a better balance of risk and benefit for selected unfit or frail patients. Supportive care with the use of corticosteroid-based prephase, prophylactic growth factors, and early institution of supportive and palliative care can help maximize treatment tolerance. Several novel or emerging therapies have demonstrated favorable toxicity profiles, thus facilitating effective treatment for elderly patients. In the relapsed or refractory setting, patients who are not candidates for stem cell transplantation can benefit from newly approved options including polatuzumab vedotin-based combinations or tafasitamab plus lenalidomide, which may have higher efficacy and/or lower toxicity than historical chemotherapy regimens. Chimeric antigen receptor T-cell therapy has been successfully applied to older patients outside of clinical trials. In the first-line setting, emerging immunotherapy options (bispecific antibodies) and targeted therapies (anti-CD20 antibodies combined with lenalidomide and/or B-cell receptor inhibitors) may provide chemotherapy-free approaches for DLBCL. Enrolling older patients in clinical trials will be paramount to fully examine potential efficacy and toxicity of these strategies. In this review, we discuss recent advances in fitness stratification and therapy that have expanded curative options for older patients, as well as future opportunities to improve outcomes in this population. IMPLICATIONS FOR PRACTICE: Management of diffuse large B-cell lymphoma in older patients poses challenges due to aggressive disease biology and geriatric vulnerability. Although R-CHOP remains standard first-line treatment, geriatric assessment may help evaluate patients' fitness for immunochemotherapy. Corticosteroid prephase, prophylactic growth factors, and early palliative care can improve tolerance of treatment. Novel salvage options (polatuzumab vedotin-based combinations, tafasitamab plus lenalidomide) or chimeric antigen receptor T-cell therapy should be considered in the relapsed or refractory setting for patients ineligible for stem cell transplantation. Emerging immunotherapies (bispecific antibodies) and targeted therapies provide potential first-line chemotherapy-free approaches, which need to be rigorously assessed in clinical trials that involve geriatric patients.
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Affiliation(s)
- Mengyang Di
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Scott F Huntington
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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18
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Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett MI. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 2020; 18:368. [PMID: 33239021 PMCID: PMC7690105 DOI: 10.1186/s12916-020-01829-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature. METHODS We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death). RESULTS One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries. CONCLUSIONS Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Helen L Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium.,Vrije Universiteit Brussel, Brussels, Belgium
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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19
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Sedhom R, Kuo PL, Gupta A, Smith TJ, Chino F, Carducci MA, Bandeen-Roche K. Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities? J Geriatr Oncol 2020; 12:361-367. [PMID: 33121909 DOI: 10.1016/j.jgo.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Place of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer. METHODS Deidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. RESULTS From 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%. CONCLUSION Hospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America.
| | - Pei-Lun Kuo
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Thomas J Smith
- Department of Palliative Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Michael A Carducci
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, United States of America
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20
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Henckel C, Revette A, Huntington SF, Tulsky JA, Abel GA, Odejide OO. Perspectives Regarding Hospice Services and Transfusion Access: Focus Groups With Blood Cancer Patients and Bereaved Caregivers. J Pain Symptom Manage 2020; 59:1195-1203.e4. [PMID: 31926969 PMCID: PMC7239741 DOI: 10.1016/j.jpainsymman.2019.12.373] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Patients with blood cancers have low rates of timely hospice use. Barriers to hospice use for this population are not well understood. Lack of transfusion access in most hospice settings is posited as a potential reason for low and late enrollment rates. OBJECTIVES We explored the perspectives of patients with blood cancers and their bereaved caregivers regarding the value of hospice services and transfusions. METHODS Between June 2018 and January 2019, we conducted three focus groups with blood cancer patients with an estimated life expectancy of six months or less and two focus groups with bereaved caregivers of patients with blood cancers. We asked participants their perspectives regarding quality of life (QOL) and about the potential association of traditional hospice services and transfusions with QOL. A hematologic oncologist, sociologist, and qualitatively trained research assistant conducted thematic analysis of the data. RESULTS Twenty-seven individuals (18 patients and nine bereaved caregivers) participated in the five focus groups. Participants identified various QOL domains that were important to them but focused largely on a desire for energy to maintain physical/functional well-being. Participants considered transfusions a high-priority service for their QOL. They also felt that standard hospice services were important for QOL. Bereaved caregivers reported overall positive experiences with hospice. CONCLUSION Our analysis suggests that although patients with blood cancers value hospice services, they also consider transfusions vital to their QOL. Innovative care delivery models that combine the elements of standard hospice services with other patient-valued services like transfusions are most likely to optimize end-of-life care for patients with blood cancers.
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Affiliation(s)
| | - Anna Revette
- Dana-Farber/Harvard Cancer Center Survey and Data Management Core, Boston, Massachusetts, USA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory A Abel
- Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Oreofe O Odejide
- Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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21
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Gatta B, LeBlanc TW. Palliative care in hematologic malignancies: a multidisciplinary approach. Expert Rev Hematol 2020; 13:223-231. [PMID: 32066301 DOI: 10.1080/17474086.2020.1728248] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Palliative care is specialized health care focused on improving the quality of life amid serious illness. Patients with hematologic malignancies have significant needs that could be addressed by a multidisciplinary palliative care team, but the integration of palliative care into hematology is far behind that of solid tumor oncology.Areas covered: This article considers what is known about the palliative care needs of hematologic malignancy patients, shows how the multidisciplinary palliative care team could improve their care, and explores how barriers to this relationship might be overcome. The evidence to support this review comes from review of recent, relevant papers known to the authors as well as PubMed searches of additional relevant articles over the past 3 years.Expert opinion: Further cultivating this relationship requires us to thoughtfully integrate the multidisciplinary palliative care team to respond to each patient's specific disease and needs, and do so at the ideal time, to maximize benefits.
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Affiliation(s)
- Brittany Gatta
- Department of Medicine, Division of General Internal Medicine, Duke Center for Palliative Care, Duke University, Durham, NC, USA
| | - Thomas W LeBlanc
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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22
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Odejide OO, Uno H, Murillo A, Tulsky JA, Abel GA. Goals of care discussions for patients with blood cancers: Association of person, place, and time with end-of-life care utilization. Cancer 2019; 126:515-522. [PMID: 31593321 DOI: 10.1002/cncr.32549] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/04/2019] [Accepted: 08/28/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with blood cancers experience high-intensity medical care near the end of life (EOL) and low rates of hospice use; attributes of goals of care (GOC) discussions may partly explain these outcomes. METHODS By using a retrospective cohort of patients with blood cancer who received care at Dana-Farber Cancer Institute and died in 2014, the authors assessed the potential relationship between timing, location, and the involvement of hematologic oncologists in the first GOC discussion with intensity of care near the EOL and timely hospice use. RESULTS Among 383 patients, 39.2% had leukemia/myelodysplastic syndromes, 37.1% had lymphoma, and 23.7% had myeloma. Overall, 65.3% of patients had a documented GOC discussion. Of the first discussions, 33.2% occurred >30 days before death, 34.8% occurred in the outpatient setting, and 46.4% included a hematologic oncologist. In multivariable analyses, having the first discussion >30 days before death (odds ratio [OR], 0.37; 95% CI, 0.17-0.81), in the outpatient setting (OR, 0.21; 95% CI, 0.09-0.50), and having a hematologic oncologist present (OR, 0.40; 95% CI, 0.21-0.77) were associated with lower odds of intensive care unit admission ≤30 days before death. The presence of a hematologic oncologist at the first discussion (OR, 3.07; 95% CI, 1.58-5.96) also was associated with earlier hospice use (>3 days before death). CONCLUSIONS In this large cohort of blood cancer decedents, most initial GOC discussions occurred close to death and in the inpatient setting. When discussions were timely, outpatient, or involved hematologic oncologists, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.
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Affiliation(s)
- Oreofe O Odejide
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Center for Lymphoma, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anays Murillo
- Tufts University School of Medicine, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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23
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Paredes AZ, Hyer JM, Tsilimigras DI, Mehta R, Sahara K, White S, Dillhoff ME, Ejaz A, Cloyd JM, Pawlik TM. Hospice utilization among Medicare beneficiaries dying from pancreatic cancer. J Surg Oncol 2019; 120:624-631. [PMID: 31290170 DOI: 10.1002/jso.25623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/21/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Use of hospice services among patients with pancreatic cancer following pancreatic resection remains unknown. METHODS Patients with pancreatic cancer who underwent resection were identified in the Medicare Standard Analytic Files. Outcomes included overall hospice use, early hospice enrollment (≥4 weeks before death), late hospice enrollment (initiation within 3 days of death), and Medicare expenditures. RESULTS Among the 4369 deceased individuals, three-fourths of patients (n = 3252, 74.4%) used hospice at the time of death. Patients who did not use hospice were more likely to be male, have a complication on index admission and receive life sustaining treatments on subsequent admissions (P < .05). Only one-third (32.2%) of patients initiated hospice services early. Medicare expenditure during the last month of life was $10 000 lower among patients who initialized hospice services at least 1 month before death versus within 3 days of death (late: $10 581 [$5454-$17 200], early: $221 [$46-$733]; P < .001) CONCLUSION: While three-fourths of patients utilized hospice services after pancreatic resection, only one-third of patients initiated hospice services at least one-month before death. Late hospice use was associated with higher Medicare expenditures during the last month of life. Further research is needed to understand barriers to early hospice utilization.
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Affiliation(s)
- Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Susan White
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
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24
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Eichenauer DA, Golla H, Thielen I, Hallek M, Voltz R, Perrar KM. Characteristics and course of patients with advanced hematologic malignancies receiving specialized inpatient palliative care at a German university hospital. Ann Hematol 2019; 98:2605-2607. [PMID: 31253997 DOI: 10.1007/s00277-019-03748-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Heidrun Golla
- Department of Palliative Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
| | - Indra Thielen
- Department of Palliative Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
| | - Michael Hallek
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
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25
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Elias R, Odejide O. Immunotherapy in Older Adults: A Checkpoint to Palliation? Am Soc Clin Oncol Educ Book 2019; 39:e110-e120. [PMID: 31099630 DOI: 10.1200/edbk_238795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The excitement about immunotherapy is justified. Patients with advanced disease and limited life expectancy before immune checkpoint inhibitors are now having prolonged and sometimes complete responses to treatment; however, most patients do not respond to checkpoint inhibitors. The hope for a meaningful response with only a limited risk of high-grade toxicity generated a prognostic dilemma for patients with advanced cancers and their treating oncologists. Older adults with advanced cancers are at the intersection of multiple biologic and clinical factors that can influence the efficacy of immunotherapy. Treating physicians should take all of these elements into account when considering treatment options for an older adult with advanced disease. Oncologists should have an honest conversation with their patients regarding the uncertainty around the clinical profile of checkpoint inhibitors. Early high-quality goals of care discussions can help manage expectations of older adults with advanced cancer treated with immunotherapy. We review in this paper select clinical characteristics that are important to consider when evaluating an older adult for checkpoint inhibitor therapy. In addition, we discuss strategies to optimize goals of care discussion given the increasing complexity of prognostication in the immunotherapy era.
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Affiliation(s)
- Rawad Elias
- 1 Hartford HealthCare Cancer Institute, Hartford Hospital, Hartford, CT
| | - Oreofe Odejide
- 2 Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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26
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Davies JM, Sleeman KE, Leniz J, Wilson R, Higginson IJ, Verne J, Maddocks M, Murtagh FEM. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002782. [PMID: 31013279 PMCID: PMC6478269 DOI: 10.1371/journal.pmed.1002782] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. METHODS AND FINDINGS MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. CONCLUSIONS In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.
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Affiliation(s)
- Joanna M. Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Julia Verne
- Health Intelligence, Public Health England, Bristol, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Fliss E. M. Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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27
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Disparities in place of death for patients with hematological malignancies, 1999 to 2015. Blood Adv 2019; 3:333-338. [PMID: 30709864 PMCID: PMC6373747 DOI: 10.1182/bloodadvances.2018023051] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/04/2018] [Indexed: 11/20/2022] Open
Abstract
Patients with hematologic malignancies (HMs) often receive aggressive end-of-life care and less frequently use hospice. Comprehensive longitudinal reporting on place of death, a key quality indicator, is lacking. Deidentified death certificate data were obtained via the National Center for Health Statistics for all HM deaths from 1999 to 2015. Multivariate regression analysis (MVA) was used to test for disparities in place of death associated with sociodemographic variables. During the study period, there were 951 435 HM deaths. Hospital deaths decreased from 54.6% in 1999 to 38.2% in 2015, whereas home (25.9% to 32.7%) and hospice facility deaths (0% to 12.1%) increased (all P < .001). On MVA of all cancers, HM patients had the lowest odds of home or hospice facility death (odds ratio [OR], 0.55; 95% confidence interval, 0.54-0.55). Older age (40-64 years: OR, 1.34; ≥65 years: OR, 1.89), being married (OR, 1.62), and having myeloma (OR, 1.34) were associated with home or hospice facility death, whereas being black or African American (OR, 0.68), Asian (OR, 0.58), or Hispanic (OR, 0.84) or having chronic leukemia (OR, 0.83) had decreased odds of dying at home or hospice (all P < .001). In conclusion, despite hospital deaths decreasing over time, patients with HMs remained more likely to die in the hospital than at home.
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28
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Philip J, Collins A, Ritchie D, Le B, Millar J, McLachlan SA, Krishnasamy M, Hudson P, Sundararajan V. Patterns of end-of-life hospital care for patients with non-Hodgkin lymphoma: exploring the landscape. Leuk Lymphoma 2019; 60:1908-1916. [PMID: 30732498 DOI: 10.1080/10428194.2018.1564047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Rapid change, treatment responsiveness, and prognostication difficulties present challenges for palliative care integration for hematology patients. This Australian study aimed to document end-of-life hospital care for patients with non-Hodgkin lymphoma (NHL) to consider opportunities for palliative care integration. A retrospective population cohort design examining existing linked datasets of health service utilization and death registration. The results revealed 4380 NHL patients, majority male (58%) and aged 70+ years (70%), spent 32 days (median) in hospital in final 6 months of life, and in the last month, 56% had more than 1 hospital admission, and 57% stayed more than 14 days. Forty-one percent accessed palliative care, with first contact 23 days (median) before death, and for 77% in final admission. Early palliative care was more likely for patients with greater symptom burden. This study mapping patterns of care for patients who die from NHL establishes a baseline enabling comparisons for future care innovations.
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Affiliation(s)
- Jennifer Philip
- a Department of Medicine , University of Melbourne , Melbourne , Australia.,b St Vincent's Hospital , Melbourne , Australia.,c Palliative Care Service, Royal Melbourne Hospital & Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Anna Collins
- a Department of Medicine , University of Melbourne , Melbourne , Australia
| | - David Ritchie
- d Department of Clinical Haematology , Royal Melbourne Hospital , Melbourne , Australia
| | - Brian Le
- c Palliative Care Service, Royal Melbourne Hospital & Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Jeremy Millar
- e Department of Radiation Oncology , Alfred Health , Melbourne , Australia
| | - Sue-Anne McLachlan
- f Department of Medical Oncology , St Vincent's Hospital Melbourne , Melbourne , Australia
| | - Meinir Krishnasamy
- g Department of Nursing , University of Melbourne , Melbourne , Australia
| | - Peter Hudson
- h Centre for Palliative Care , St Vincent's Hospital & University of Melbourne & Vrije University , Brussels , Belgium
| | - Vijaya Sundararajan
- a Department of Medicine , University of Melbourne , Melbourne , Australia.,i Department of Public Health , La Trobe University , Australia
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29
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Chino F, Kamal AH, Leblanc TW, Zafar SY, Suneja G, Chino JP. Place of death for patients with cancer in the United States, 1999 through 2015: Racial, age, and geographic disparities. Cancer 2018; 124:4408-4419. [DOI: 10.1002/cncr.31737] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/18/2018] [Accepted: 08/02/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Fumiko Chino
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Arif H. Kamal
- Division of Medical Oncology and Palliative Care, Duke Cancer Institute; Durham North Carolina
| | - Thomas W. Leblanc
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute; Durham North Carolina
| | - S. Yousuf Zafar
- Division of Medical Oncology and Palliative Care, Duke Cancer Institute; Durham North Carolina
| | - Gita Suneja
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Junzo P. Chino
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
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30
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LeBlanc TW, Egan PC, Olszewski AJ. Transfusion dependence, use of hospice services, and quality of end-of-life care in leukemia. Blood 2018; 132:717-726. [PMID: 29848484 PMCID: PMC6097134 DOI: 10.1182/blood-2018-03-842575] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/28/2018] [Indexed: 12/11/2022] Open
Abstract
Hospice provides high-quality end-of-life care, but patients with leukemias use hospice services less frequently than those with solid tumors. Transfusion dependence (TD) may hinder or delay enrollment, because hospice organizations typically disallow transfusions. We examined the association between TD and end-of-life outcomes among Medicare beneficiaries with leukemia. From the Surveillance, Epidemiology, and End Results-Medicare database, we selected beneficiaries with acute and chronic leukemias who died in 2001-2011. We defined TD as ≥2 transfusions within 30 days before death or hospice enrollment. End points included hospice enrollment and length of stay, reporting relative risk (RR) adjusted for key covariates. Among 21 033 patients with a median age of 79 years, 20% were transfusion dependent before death/hospice enrollment. Use of hospice increased from 35% in 2001 to 49% in 2011. Median time on hospice was 9 days and was shorter for transfusion-dependent patients (6 vs 11 days; P < .001). Adjusting for baseline characteristics, TD was associated with a higher use of hospice services (RR, 1.08; 95% confidence interval [CI], 1.04-1.12) but also with 51% shorter hospice length of stay (RR, 0.49; 95% CI, 0.44-0.54). Hospice enrollees had a lower likelihood of inpatient death and chemotherapy use and lower median Medicare spending at end-of-life, regardless of TD status. In conclusion, relatively increased hospice use combined with a markedly shorter length of stay among transfusion-dependent patients suggests that they have a high and incompletely met need for hospice services and that they experience a barrier to timely referral. Policy solutions supporting palliative transfusions may maximize the benefits of hospice for leukemia patients.
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Affiliation(s)
- Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Pamela C Egan
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI; and
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI; and
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
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31
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Early Palliative Care for Patients with Hematologic Malignancies: Is It Really so Difficult to Achieve? Curr Hematol Malig Rep 2018. [PMID: 28639084 DOI: 10.1007/s11899-017-0392-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Evidence points to many benefits of "early palliative care," the provision of specialist palliative care services upstream from the end of life, to improve patients' quality of life while living with a serious illness. Yet most trials of early palliative care have not included patients with hematologic malignancies. Unfortunately, patients with hematologic malignancies are also known to have substantial illness burden, poor quality of life, and aggressive care at the end of life, including a greater likelihood of dying in the hospital, receiving chemotherapy at the end of life, and low hospice utilization, compared to patients with solid tumors. Given these unmet needs, one must wonder, why is palliative care so underutilized in this population? In this article, we discuss barriers to palliative care integration in hematology, highlight several reports of successful integration, and suggest specific indications for involving palliative care in the management of hematologic malignancy patients.
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32
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Odejide OO, Li L, Cronin AM, Murillo A, Richardson PG, Anderson KC, Abel GA. Meaningful changes in end-of-life care among patients with myeloma. Haematologica 2018; 103:1380-1389. [PMID: 29748440 PMCID: PMC6068022 DOI: 10.3324/haematol.2018.187609] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
Patients with advanced myeloma experience a high symptom burden particularly near the end of life, making timely hospice use crucial. Little is known about the quality and determinants of end-of-life care for this population, including whether potential increases in hospice use are also accompanied by “late” enrollment (≤ 3 days before death). Using the Surveillance, Epidemiology, and End-Results-Medicare database, we identified patients ≥ 65 years diagnosed with myeloma between 2000 and 2013 who died by December 31, 2013. We assessed prevalence and trends in hospice use, including late enrollment. We also examined six established measures of potentially aggressive medical care at the end of life. Independent predictors of late hospice enrollment and aggressive end-of-life care were assessed using multivariable logistic regression analyses. Of 12,686 myeloma decedents, 48.2% enrolled in hospice. Among the 6111 who enrolled, 17.2% spent ≤ 3 days there. There was a significant trend in increasing hospice use, from 28.5% in 2000 to 56.5% by 2013 (Ptrend <0.001), no significant rise in late enrollment (12.2% in 2000 to 16.3% in 2013, Ptrend =0.19), and a slight decrease in aggressive end-of-life care (59.2% in 2000 to 56.7% in 2013, Ptrend =0.01). Patients who were transfusion-dependent, on dialysis, or survived for less than one year were more likely to enroll late in hospice and experience aggressive medical care at the end of life. Gains in hospice use for myeloma decedents were not accompanied by increases in late enrollment or aggressive medical care. These findings suggest meaningful improvements in end-of-life care for this population.
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Affiliation(s)
- Oreofe O Odejide
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA .,Center for Lymphoma, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ling Li
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angel M Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anays Murillo
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Gregory A Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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33
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Levine DR, Baker JN, Wolfe J, Lehmann LE, Ullrich C. Strange Bedfellows No More: How Integrated Stem-Cell Transplantation and Palliative Care Programs Can Together Improve End-of-Life Care. J Oncol Pract 2018; 13:569-577. [PMID: 28898603 DOI: 10.1200/jop.2017.021451] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In the intense, cure-oriented setting of hematopoietic stem-cell transplantation (HSCT), delivery of high-quality palliative and end-of-life care is a unique challenge. Although HSCT affords patients a chance for cure, it carries a significant risk of morbidity and mortality. During HSCT, patients usually experience high symptom burden and a significant decrease in quality of life that can persist for long periods. When morbidity is high and the chance of cure remote, the tendency after HSCT is to continue intensive medical interventions with curative intent. The nature of the complications and overall condition of some patients may render survival an unrealistic goal and, as such, continuation of artificial life-sustaining measures in these patients may prolong suffering and preclude patient and family preparation for end of life. Palliative care focuses on the well-being of patients with life-threatening conditions and their families, irrespective of the goals of care or anticipated outcome. Although not inherently at odds with HSCT, palliative care historically has been rarely offered to HSCT recipients. Recent evidence suggests that HSCT recipients would benefit from collaborative efforts between HSCT and palliative care services, particularly when initiated early in the transplantation course. We review palliative and end-of-life care in HSCT and present models for integrating palliative care into HSCT care. With open communication, respect for roles, and a spirit of collaboration, HSCT and palliative care can effectively join forces to provide high-quality, multidisciplinary care for these highly vulnerable patients and their families.
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Affiliation(s)
- Deena R Levine
- St Jude Children's Research Hospital, Memphis, TN; Dana-Farber Cancer Institute; and Boston Children's Hospital, Boston, MA
| | - Justin N Baker
- St Jude Children's Research Hospital, Memphis, TN; Dana-Farber Cancer Institute; and Boston Children's Hospital, Boston, MA
| | - Joanne Wolfe
- St Jude Children's Research Hospital, Memphis, TN; Dana-Farber Cancer Institute; and Boston Children's Hospital, Boston, MA
| | - Leslie E Lehmann
- St Jude Children's Research Hospital, Memphis, TN; Dana-Farber Cancer Institute; and Boston Children's Hospital, Boston, MA
| | - Christina Ullrich
- St Jude Children's Research Hospital, Memphis, TN; Dana-Farber Cancer Institute; and Boston Children's Hospital, Boston, MA
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34
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Forst D, Adams E, Nipp R, Martin A, El-Jawahri A, Aizer A, Jordan JT. Hospice utilization in patients with malignant gliomas. Neuro Oncol 2018; 20:538-545. [PMID: 29045712 PMCID: PMC5909651 DOI: 10.1093/neuonc/nox196] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Despite recommendations from professional organizations supporting early hospice enrollment for patients with cancer, little research exists regarding end-of-life (EOL) practices for patients with malignant glioma (MG). We evaluated rates and correlates of hospice enrollment and hospice length of stay (LOS) among patients with MG. Methods Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified adult patients who were diagnosed with MG from January 1, 2002 to December 31, 2011 and who died before December 31, 2012. We extracted sociodemographic and clinical data and used univariate logistic regression analyses to compare characteristics of hospice recipients versus nonrecipients. We performed multivariable logistic regression analyses to examine predictors of hospice enrollment >3 or >7 days prior to death. Results We identified 12437 eligible patients (46% female), of whom 7849 (63%) were enrolled in hospice before death. On multivariable regression analysis, older age, female sex, higher level of education, white race, and lower median household income predicted hospice enrollment. Of those enrolled in hospice, 6996 (89%) were enrolled for >3 days, and 6047 (77%) were enrolled for >7 days. Older age, female sex, and urban residence were predictors of longer LOS (3- or 7-day minimum) on multivariable analysis. Median LOS on hospice for all enrolled patients was 21 days (interquartile range, 8-45 days). Conclusions We identified important disparities in hospice utilization among patients with MG, with differences by race, sex, age, level of education, and rural versus urban residence. Further investigation of these barriers to earlier and more widespread hospice utilization is needed.
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Affiliation(s)
- Deborah Forst
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric Adams
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan Nipp
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison Martin
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
| | - Areej El-Jawahri
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ayal Aizer
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
| | - Justin T Jordan
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA. Palliative care specialists' perceptions concerning referral of haematology patients to their services: findings from a qualitative study. BMC Palliat Care 2018; 17:33. [PMID: 29466968 PMCID: PMC5822662 DOI: 10.1186/s12904-018-0289-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/13/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals. METHODS We conducted a qualitative study, set within the United Kingdom's (UK's) Haematological Malignancy Research Network (HMRN: www.hmrn.org ), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the 'Framework' method. RESULTS Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to 'flag' patients' needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time. CONCLUSIONS This is the first UK study to explore SPC practitioners' perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Russell D Patmore
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Martin R Howard
- Department of Haematology, York Hospital, York, YO31 8HE, UK
| | - Debra A Howell
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
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Beaussant Y, Daguindau E, Chauchet A, Rochigneux P, Tournigand C, Aubry R, Morin L. Hospital end-of-life care in haematological malignancies. BMJ Support Palliat Care 2018; 8:314-324. [PMID: 29434048 DOI: 10.1136/bmjspcare-2017-001446] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate patterns of care during the last months of life of hospitalised patients who died from different haematological malignancies. METHODS Nationwide register-based study, including all hospitalised adults ≥20 years who died from haematological malignancies in France in 2010-2013. Outcomes included use of invasive cancer treatments and referral to palliative care. Percentages are adjusted for sex and age using direct standardisation. RESULTS Of 46 629 inpatients who died with haematological malignancies, 24.5% received chemotherapy during the last month before death, 48.5% received blood transfusion, 12.3% were under invasive ventilation and 18.1% died in intensive care units. We found important variations between haematological malignancies. The use of chemotherapy during the last month of life varied from 8.6% among patients with chronic myeloid leukaemia up to 30.1% among those with non-Hodgkin's lymphoma (P<0.001). Invasive ventilation was used in 10.2% of patients with acute leukaemia but in 19.0% of patients with Hodgkin's lymphoma (P<0.001). Palliative status was reported 30 days before death in only 14.8% of patients, and at time of death in 46.9% of cases. Overall, 5.5% of haematology patients died in palliative care units. CONCLUSION A high proportion of patients who died from haematological malignancies receive specific treatments near the end of life. There is a need for a better and earlier integration of the palliative care approach in the standard practice of haematology. However, substantial variation according to the type of haematological malignancy suggests that the patients should not be considered as one homogeneous group. Implementation of palliative care should account for differences across haematological malignancies.
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Affiliation(s)
- Yvan Beaussant
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Etienne Daguindau
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Adrien Chauchet
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Philippe Rochigneux
- Department of Medical Oncology, Paoli-Calmettes Cancer Institute, Marseille, France
| | - Christophe Tournigand
- Department of Medical Oncology, Hopital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France.,Paris-Est Creteil University, Créteil, France
| | - Régis Aubry
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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Westin GF, Dias AL, Go RS. Exploring Big Data in Hematological Malignancies: Challenges and Opportunities. Curr Hematol Malig Rep 2017; 11:271-9. [PMID: 27177742 DOI: 10.1007/s11899-016-0331-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Secondary analysis of large datasets has become a useful alternative to address research questions outside the reach of clinical trials. It is increasingly utilized in hematology and oncology. In this review, we provided an overview of some examples of commonly used large datasets in the USA and described common research themes that can be pursued using such a methodology. We selected a sample of 14 articles on adult hematologic malignancies published in 2015 and highlighted their contributions as well as limitations.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Databases, Factual
- Hematologic Neoplasms/diagnosis
- Hematologic Neoplasms/economics
- Hematologic Neoplasms/pathology
- Hematologic Neoplasms/therapy
- Hematopoietic Stem Cell Transplantation
- Hodgkin Disease/diagnosis
- Hodgkin Disease/economics
- Hodgkin Disease/pathology
- Hodgkin Disease/therapy
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/economics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/economics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Multiple Myeloma/diagnosis
- Multiple Myeloma/economics
- Multiple Myeloma/pathology
- Multiple Myeloma/therapy
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Affiliation(s)
- Gustavo F Westin
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajoy L Dias
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Abstract
Measuring the quality of care for patients with chronic cancers is difficult, especially for heterogeneous malignancies such as the myelodysplastic syndromes (MDS). Recent work suggests that improvements may be needed in the quality of diagnostic, treatment, and end-of-life care for patients with these syndromes. Moreover, rigorous assessment of factors that are necessary to deliver high-quality care such as preferred method of decision-making and pre-treatment quality of life are often overlooked. Finally, a key component of quality care is that it is received equitably across different patient populations, yet several recent studies suggest that there are financial, educational, race-ethnic, and age-related barriers to equitable MDS care.
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Affiliation(s)
| | - Gregory A Abel
- Division of Population Sciences and Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Nickolich M, El-Jawahri A, LeBlanc TW. Palliative and End-of-Life Care in Myelodysplastic Syndromes. Curr Hematol Malig Rep 2017; 11:434-440. [PMID: 27704467 DOI: 10.1007/s11899-016-0352-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A growing literature demonstrates that MDS is associated with significant impairments in overall quality of life. Given the poor prognosis for many patients with MDS, and the considerable morbidities associated with this disease, there is a critical need to address palliative and end-of-life care needs in this population. However, palliative and end-of-life care issues are under-represented in the MDS literature. In this article, we highlight a growing body of literature that demonstrates unmet palliative and end-of-life care needs in hematologic malignancies, including MDS, and highlight opportunities for further research and quality improvement initiatives to address unmet needs in MDS care.
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Affiliation(s)
- Myles Nickolich
- Divisions of Hematology, Medical Oncology, and Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Thomas W LeBlanc
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA. .,DUMC, Box 2715, Durham, NC, 27710, USA.
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McCaughan D, Roman E, Smith AG, Garry A, Johnson M, Patmore R, Howard M, Howell DA. Determinants of hospital death in haematological cancers: findings from a qualitative study. BMJ Support Palliat Care 2017; 8:78-86. [PMID: 28663341 PMCID: PMC5867428 DOI: 10.1136/bmjspcare-2016-001289] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/07/2017] [Accepted: 05/20/2017] [Indexed: 11/10/2022]
Abstract
Objectives Current UK health policy promotes enabling people to die in a place they choose, which for most is home. Despite this, patients with haematological malignancies (leukaemias, lymphomas and myeloma) are more likely to die in hospital than those with other cancers, and this is often considered a reflection of poor quality end-of-life care. This study aimed to explore the experiences of clinicians and relatives to determine why hospital deaths predominate in these diseases. Methods The study was set within the Haematological Malignancy Research Network (HMRN—www.hmrn.org), an ongoing population-based cohort that provides infrastructure for evidence-based research. Qualitative interviews were conducted with clinical staff in haematology, palliative care and general practice (n=45) and relatives of deceased HMRN patients (n=10). Data were analysed for thematic content and coding and classification was inductive. Interpretation involved seeking meaning, salience and connections within the data. Results Five themes were identified relating to: the characteristics and trajectory of haematological cancers, a mismatch between the expectations and reality of home death, preference for hospital death, barriers to home/hospice death and suggested changes to practice to support non-hospital death, when preferred. Conclusions Hospital deaths were largely determined by the characteristics of haematological malignancies, which included uncertain trajectories, indistinct transitions and difficulties predicting prognosis and identifying if or when to withdraw treatment. Advance planning (where possible) and better communication between primary and secondary care may facilitate non-hospital death.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Anne Garry
- Department of Palliative Care, York Hospital, York, UK
| | - Miriam Johnson
- Centre for Health and Population Sciences, University of Hull, Hull, UK
| | - Russell Patmore
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, UK
| | | | - Debra A Howell
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
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Wang X, Knight LS, Evans A, Wang J, Smith TJ. Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer. J Oncol Pract 2017; 13:e496-e504. [PMID: 28221897 DOI: 10.1200/jop.2016.018093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The benefits of hospice for patients with end-stage disease are well established. Although hospice use is increasing, a growing number of patients are enrolled for ≤ 7 days, a marker of poor quality of care and patient and family dissatisfaction. In this study, we examined variations in referrals among individuals and groups of physicians to assess a potential source of suboptimal hospice use. METHODS We conducted a retrospective chart review of 452 patients with advanced cancer referred to hospice from a comprehensive cancer center. We analyzed patient length of service (LOS) under hospice care, looking specifically at median LOS and percent of short enrollments (%LOS ≤ 7), to examine the variation between individual oncologists and divisions of oncologists. RESULTS Of 394 successfully referred patients, median LOS was 14.5 days and %LOS ≤ 7 was 32.5%, consistent with national data. There was significant interdivisional variation in LOS, both by overall distribution and %LOS ≤ 7 ( P < .01). In addition, there was dramatic variation in median LOS by individual physician (range, 4 to 88 days for physicians with five or more patients), indicating differences in hospice referral practices between providers (coefficient of variation > 125%). As one example, median LOS of physicians in the Division of Thoracic Malignancies varied from 4 to 33 days, despite similarities in patient population. CONCLUSION Nearly one in three patients with cancer who used hospice had LOS ≤ 7 days, a marker of poor quality. There was significant LOS variability among different divisions and different individual physicians, suggesting a need for increased education and training to meet recommended guidelines.
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Affiliation(s)
- Xiao Wang
- The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD
| | - Louise S Knight
- The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD
| | - Anne Evans
- The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD
| | - Jiangxia Wang
- The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD
| | - Thomas J Smith
- The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD
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Odejide OO, Cronin AM, Condron NB, Fletcher SA, Earle CC, Tulsky JA, Abel GA. Barriers to Quality End-of-Life Care for Patients With Blood Cancers. J Clin Oncol 2016; 34:3126-32. [DOI: 10.1200/jco.2016.67.8177] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with blood cancers have been shown to receive suboptimal care at the end of life (EOL) when assessed with standard oncology quality measures (eg, no chemotherapy ≤ 14 days before death). As they were developed primarily for solid tumors, it is unclear if these measures are appropriate for patients with hematologic malignancies. Moreover, barriers to high-quality EOL care for this specific patient population are largely unknown. Methods In 2015, we asked a national cohort of hematologic oncologists about the acceptability of eight standard EOL quality measures. Building on prior qualitative work, we prespecified that measures achieving agreement among at least 55% of respondents would be considered acceptable. We also explored perspectives regarding barriers to quality EOL care. Results We received 349 surveys (response rate = 57.3%). Six of the standard measures met the threshold of acceptability, and four were acceptable to > 75% of respondents: hospice admission > 7 days before death, no chemotherapy ≤ 14 days before death, no intubation in the last 30 days of life, and no cardiopulmonary resuscitation in the last 30 days of life. The highest-ranked barriers to quality EOL care reported were “unrealistic patient expectations” (97.3%), “clinician concern about taking away hope” (71.3%), and “unrealistic clinician expectations” (59.0%). Conclusion In this large national cohort of hematologic oncologists, standard EOL quality measures were highly acceptable. The top barrier to quality EOL care reported was unrealistic patient expectations, which may be best addressed with more timely and effective advance care discussions.
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Affiliation(s)
- Oreofe O. Odejide
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Angel M. Cronin
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Nolan B. Condron
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Sean A. Fletcher
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Craig C. Earle
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - James A. Tulsky
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Gregory A. Abel
- Oreofe O. Odejide, Angel M. Cronin, Nolan B. Condron, Sean A. Fletcher, James A. Tulsky, Gregory A. Abel, Dana-Farber Cancer Institute; James A. Tulsky, Brigham and Women’s Hospital, Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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Trevino KM, Martin P, Prigerson HG. Evaluating Quality Metrics for the Care of Patients With Blood Cancer Who Are Near Death. J Clin Oncol 2016; 34:3117-8. [DOI: 10.1200/jco.2016.68.8911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kelly M. Trevino
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY
| | - Peter Martin
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY
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