High Need for Palliative Care Among Cancer Patients

Roxanne Nelson

February 17, 2011

February 17, 2011 — Even though surveys of healthy adults have suggested that most individuals would prefer to die at home, that does not seem to be the reality. More than 50% of Americans with serious illnesses die in acute care hospitals, and the vast majority of Medicare beneficiaries (>90%) will be hospitalized during the year preceding their death.

Therefore, palliative care has become an integral aspect of care provided by acute care hospitals, say researchers in a study published in the Februay 20 issue of the Journal of Clinical Oncology.

They analyzed the need for palliative care in 39,849 patients who were hospitalized at a large university medical center in Germany, and found that 6.9% were considered to have palliative care needs (PCNs).

Patients with head and neck cancer had a particularly high rate of PCNs (28.3%), followed by those with malignant melanoma (26%) and brain tumors (18.2%). Among patients with metastatic disease, the risk of developing PCNs was increased 12-fold (odds ratio, 12.27).

Although there is a growing body of evidence that patients with nonmalignant diseases also have PCNs, the results of this study illustrate the fact that nearly two thirds of hospital patients (67%) requiring palliative care are those with cancer, write lead author Gerhild Becker, MD, MSc, from the University Medical Center Freiburg in Germany, and colleagues.

"Since having or not having access to palliative care is an important topic of health inequity, further development of infrastructures for both research and education in palliative care is strongly recommended," they note.

Patients Older

The data come from the University Medical Center Freiburg, one of the largest hospitals in Europe, with 1479 hospital beds in 42 clinical departments.

During the study period, which was conducted from January 2004 to May 2005, nearly 7% of all patients and 9.1% of patients older than 65 years had PCNs.

Patients with PCNs were significantly older than those not requiring palliative care (P < .001), with 52.9% being at least 65 years of age. Since this population was older, the authors conducted a secondary analysis in which they compared only patients 65 years and older. They found that even in this older group, almost two thirds (63%) of patients with PCNs had cancer.

Significantly more patients with PCNs died during their hospital stay (4.5% vs 2.5%; P < .001) or were discharged to a different facility than were discharged home (8.3% vs 3.8%; P < .001).

Cancer Highest Risk Factor

The authors also observed that a cancer diagnosis was the highest risk factor for the development of PCNs, with an odds ratio of 3.63 (95% confidence interval [CI], 3.27 to 4.04). This extrapolated to a 3.63 times greater risk of needing palliative care.

The presence of metastases increased the risk by a factor of 3.38 (95% CI, 3.04 to 3.75). Therefore, they note, having metastatic cancer increases the risk of developing PCNs by a factor of 12.27. In contrast, older age only increased the odds ratio by 1.48 (95% CI, 1.36 to 1.61).

The majority of cancer patients requiring palliative care had gastrointestinal tumors (18.8% of all patients with PCNs), followed by those with lung cancer (9.2%), lymphoma (7.0%), breast cancer (4.8%), cancer of the brain (4.0%), cancer of the female genital organs (3.4%), and cancer of the male genital organs (3.1%).

More than one third (38.7%) of patients with PCNs had metastases, compared with only 8.6% of those without PCNs (P < .001).

In other words, the authors note, 25.1% of 4256 patients with metastases were classified as having PCNs. Within this group, patients with brain metastases showed a particularly high rate of PCNs (38.9%), followed by patients with bone metastases (36.3%).

Among cancer patients with PCNs, 32% (n = 580) received chemotherapy and/or radiotherapy: 18.3% received chemotherapy, 11.4% received radiotherapy, and 2.4% received a combination of chemotherapy and radiotherapy.

"Recent research highlighted [the fact] that although most [American] cancer centers claim that they provide palliative care, the scope of services and the degree of integration [vary] widely," write the authors. "There remain significant gaps in the delivery of care, and further efforts to consolidate existing infrastructure and to integrate palliative care in cancer centers are warranted."

The study was funded by Roche Pharma, Germany. The researchers have disclosed no relevant financial relationships.

J Clin Oncol. 2011;29:646-650. Abstract

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