The rise of concurrent care for veterans with advanced cancer at the end of life

BACKGROUND

Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.

METHODS

This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment.

RESULTS

The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012).

CONCLUSIONS

Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.

Variations in use and timing of hospice and palliative care: Differences across health care payers and cancer type

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Background: Cancer societies recommend cancer patients receive palliative care soon after diagnosis of illness and hospice for at least 3 days before death. While studies suggest receipt of hospice in the last 3 days of life is increasing for patients, the timing of first hospice and first palliative care is currently unknown. It is also not known whether fee-for-service versus capitated healthcare systems differ in their provision of supportive care. We evaluated the timing and frequency of palliative care and hospice use across the Department of Veterans Affairs (VA) and Medicare for dually-eligible Veterans, to understand variations in the use and timing of these services across healthcare systems for the same patient population. Methods: A retrospective evaluation of all VA and Medicare administrative data for the population of Veterans aged 65 or older who died with advanced cancer in 2012. Results: The majority of Veterans received supportive care before death: 67% received hospice and 69% received palliative care. On average, patients had 2 encounters with palliative care before death. Patients with melanoma were most likely to receive palliative care (82%); patients with hematologic malignancies were least likely to receive palliative care (58%). Veterans received VA-based hospice on average 35 days before death (SD = 42), while Veterans receiving Medicare-based hospice did so an average of 25 days before death (SD = 24). However, across both systems, 50% of Veterans were receiving hospice 16 days before death. There were substantial variations in timing of hospice enrollment by cancer type. Of Veterans receiving VA- or Medicare-based hospice, 22% cycled in and out of hospice, meaning they dis-enrolled and re-enrolled in such care. 16% of patients were discharged from hospice before death, with VA more likely to discharge Veterans before death compared with Medicare. Conclusions: There are large variations in healthcare system approaches to timing and use of hospice and palliative care, as well variations by cancer type. VA provides hospice to patients earlier in the disease trajectory, while Medicare is more likely to have patients die while enrolled in hospice.

Patient expectations of palliative cancer treatment for noncurable malignancies: A pilot study

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Background: Many people with advanced non-curable malignancies have unrealistic expectations of palliative cancer treatment including a belief that treatment may cure their cancer. However, qualitative data describing how patients define “cure” or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anti-cancer treatment. Methods: Patients with advanced non-curable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, co-morbidities, and palliative care involvement. Results: We enrolled 30 patients initiating non-curative anti-cancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancer. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of “cure” ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.” Conclusions: Patient-reported definitions of “cure” and other treatment goals vary widely and a substantial number of patients report unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments. “The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.”

Assessment of the effectiveness of a chemotherapy education program: A Brown University Oncology Research Group study

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Background: Patients about to begin chemotherapy often have questions about their treatment along with significant anxiety. This study evaluated whether pre-chemotherapy teaching sessions improved patient knowledge and anxiety. Methods: After meeting with their oncologist to discuss planned chemotherapy treatment, subjects completed a 10-question survey which assessed their knowledge of anticipated side effects and treatment schedule on a 1-4 rating scale (1=no knowledge, 2=minimally informed, 3=reasonably informed, 4=well informed) as well as anxiety about initiating chemotherapy (1=no anxiety, 2=minimal anxiety, 3=moderate anxiety, 4=severe anxiety). Subjects then completed a structured nurse-led chemotherapy education session. The survey was repeated on the first day of cycle 1. Mantel-Haentzel Chi-square tests were used to evaluate for changes across the surveys. Subgroup analysis by Wilcoxon signed-rank test was performed to assess differences in anxiety based on age. Results: At the time of analysis, 142 subjects had completed the education session. Improvement was seen in knowledge of treatment schedule (mean score increase from 2.5 to 3.4, p<0.001), side effects (mean score increase from 2.3 to 3.4, p<0.001), and how to use medications designed to prevent and treat nausea (mean score increase from 1.8 to 3.2, p<0.001). There was significant reduction in patient anxiety about starting treatment (mean score decrease from 2.3 to 2, p<0.001) and anxiety related to treatment side effects (mean score decrease from 2.3 to 2, p<0.001). Analysis of anxiety by age showed that those age <65 had higher baseline anxiety scores with a reduction in anxiety after the education session while those age ≥65 had lower baseline anxiety scores with a rise in anxiety after the education session (Table). Conclusions: A pre-chemotherapy teaching session improves patient knowledge about the planned treatment along with reduction in anxiety. Change in anxiety differs between patients 65 years of age and older as compared to those less than 65. [Table: see text]

Assessment of the effectiveness of a prechemotherapy teaching session: A Brown University Oncology Group study

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Background: Pre-chemotherapy teaching sessions, often coordinated by nursing personnel, are an opportunity to educate patients on treatment side effects, schedule, medications for toxicities such as nausea, and how to contact the oncology team if adverse events develop. Our institution provides a structured 60-minute nurse-coordinated pre-chemotherapy teaching session. The aims of this study were to evaluate whether pre-chemotherapy teaching sessions improve patient knowledge, preparedness, and anxiety in relation to chemotherapy. Methods: Patients were offered the opportunity to participate in the study after their medical oncologist had reviewed their treatment regimen. After informed consent was obtained, participants were administered a 10-question survey assessing knowledge of treatment adverse effects, treatment schedule, management of complications, accessing their medical team, and patient anxiety. Subjects then participated in a pre-chemotherapy teaching session with an oncology nurse. The survey was readministered when patients returned on day 1, cycle 1 of treatment and on day 1, cycle 2. The questionnaire used a 1 to 4 rating scale (1=no knowledge, 2= minimally informed, 3= reasonably informed, 4= well informed). A pre-defined mean change of 1 on the rating scale was considered to be clinically significant. Paired one-sided t-tests were performed to evaluate the mean change in groups between each of the three surveys. p values <0.05 were considered statistically significant. Results: At the time of analysis, 78 patients had completed a pre-chemotherapy teaching session and all three surveys. After participating in a teaching session, there was an increase in patient’s perceived knowledge of side effects (mean score 2.3 vs. 3.5, p<0.001), knowledge of the treatment schedule (mean score 2.4 vs. 3.5, p<0.001) and medications to prevent nausea (mean score of 1.4 vs. 3.1, p <0.001). There was also a statistically significant reduction in patient anxiety in relation to treatment, p< 0.001. Conclusions: These results show that a nurse-coordinated, pre-chemotherapy teaching session increases patient knowledge and reduces anxiety regarding their upcoming treatment.

Lenalidomide for second-line treatment of advanced hepatocellular cancer (HCC): A Brown University Oncology Group phase II study

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Background: Lenalidomide inhibits fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF) and multiple tumor growth pathways. There is no standard of care for patients who progress after sorafenib. Therefore, we performed a phase II study to determine the activity of lenalidomide in second-line HCC therapy. Methods: Patients with advanced HCC who progressed on or were intolerant to sorafenib were eligible. Prior chemoembolization, RFA, or surgery were allowed. Eligibility criteria also included bilirubin <4 mg/dL, AST and ALT <5 times upper limit of normal, ECOG performance status 0-2, platelet count >60,000/mm3, absolute neutrophil count >1000/mm3, and creatinine <2mg/dL. Patients were treated with lenalidomide 25mg orally days 1-21 of a 28 day cycle until disease progression or unacceptable toxicities. The planned original sample size was 25 patients but when early activity was demonstrated the study was expanded to 40 patients. Results: The study has completed accrual of 40 patients. The median age was 60.5 years (17-88 years). Nineteen patients were Child-Pugh A, 16 patients were B, and 5 patients were C. Twenty four patients had extrahepatic disease. Preliminary data is available on the first 37 patients. One patient had grade 4 neutropenia. Grade 3 toxicities included ANC (n=2), fatigue (n=4), rash (n=2), arthritis (n=1), diarrhea (n=1), dehydration (n=2). One patient developed variceal bleeding which precipitated encephalopathy and death. Of the 32 patients with elevated baseline AFP, nine (28%) had a >50% reduction including one patient with a reduction in AFP from 56,900ng/ml to 5 ng/ml. Six of the first 37 patients (16%) had a radiographic partial response. Two patients achieved a complete response and have not progressed at 36 and 32 months. Conclusions: Lenalidomide can be administered to patients with advanced HCC and significant hepatic dysfunction. Promising, and in a small percentage of patients, dramatic and durable activity has been demonstrated. Investigations are underway to explore the mechanism of action of lenalidomide in HCC.