Meg Barbor

July 20, 2015

COPENHAGEN, Denmark ― Patients with hematologic malignancies often receive more aggressive care at the end of life compared with patients with solid tumors, according to a recent study conducted at the University of Texas MD Anderson Cancer Center, in Houston, Texas.

However, it is uncertain whether these differences in end-of-life-care practices are due to differences in patient characteristics/disease trajectory, perceived prognosis, perceived treatment risks and benefits, or oncology professionals' attitudes toward end-of-life care.

The investigators, headed by David Hui, MD, from the Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, MD Anderson Cancer Center, conducted a single- institution study to better understand the end-of-life decision-making process among oncology specialists. They compared cancer treatment recommendations, as well as attitudes and beliefs toward palliative care, of specialists treating hematologic malignancies with those of physicians dealing with solid tumors.

Dr Hui and colleagues presented the results here at the Multinational Association of Supportive Care in Cancer (MASCC) Annual Meeting.

Study Methods

"The first three factors involved in the differentiation of end-of-life-care practices [patient characteristics/disease trajectory, perceived prognosis, perceived treatment risks and benefits] are very hard to change," said Dr Hui. "But the fourth [oncology professionals' attitudes toward end-of-life care] is potentially modifiable.

"We decided to investigate that further by using a standardized case vignette. These cases allow us to control for the first three factors, and thus, a majority of the variation may be explained by the oncologists' attitudes and beliefs."

Dr Hui and his colleagues also sought to examine factors associated with cancer treatment recommendations, such as the decision to give chemotherapy to a patient with 1 month left to live.

Investigators conducted a survey of a random sample of 120 solid-tumor oncologists and 120 hematologic oncologists; within each group, half were clinicians, and the other half were mid-level providers.

Respondents completed a survey examining three aspects of end-of-life care: palliative systemic therapy using standardized case vignettes on cancer treatment decisions, self-perceived palliative care skills, and specialist palliative care referral.

"Each respondent completed three case vignettes, which differed only in regard to performance status and survival," Dr Hui explained.

The first vignette posed a scenario in which the clinician must choose palliative systemic therapy or no systemic therapy (ie, chemotherapy and targeted agents) for a patient with an ECOG performance status (PS) of 2 and estimated survival of 6 months. The second and third vignettes posed the same choice for patients with ECOG PS 3, survival 3 months, and ECOG PS 4, survival 1 month, respectively.

Each clinician marked a scale of 1 to 7, with 1 being strongly against treatment and 7 strongly in favor of recommending treatment.

Hematologic Specialists More Likely to Favor Systemic Therapy

In total, 182/240 (76%) clinicians responded. In the first vignette (ECOG PS 2, survival 6 months), "both solid-tumor and hematologic oncologists would recommend treatment most of the time to their patients," reported Dr Hui.

In the second vignette (ECOG PS 3, survival 3 months), "we start to see that solid-tumor oncologists are less enthusiastic about recommending treatment, whereas hematologic oncologists also have a shift to the left, but they're more in the undecided range," he noted.

"The third case (ECOG PS 4, survival 1 months) was of most interest to us because we found that the distribution is no longer a bell curve but a U-shaped distribution," he said. "So that means some oncologists strongly believe we should not be giving treatment, while others strongly feel that we should."

In this group, compared with solid tumor specialists, hematologic specialists were more likely to favor prescribing systemic therapy with moderate toxicity and no survival benefit.

Wide Variation in Approach to End-of-Life Care

Investigators also compared self-reported end-of-life practices between the two groups of oncologists. "In general, hematologic oncologists were found to be less comfortable with end-of-life- care issues," said Dr Hui.

Hematologic oncologists felt less comfortable in comparison with solid-tumor specialists about discussing death and dying (72% vs 88%), less comfortable referring patients to hospice care (81% vs 93%), and more likely to feel a sense of failure when unable to alter the course of disease (46% vs 31%).

"I think you've got to look at the difference between the patients they're treating and the outcomes they expect," said Ian Olver, MD, moderator of the session and director of the Sansom Institute for Health Research at the University of South Australia, in Adelaide.

"Hematologic oncologists in general will be treating younger patients with a higher cure rate than solid-tumor oncologists, and they'll have a higher response rate as well. So they have a greater expectation of the results of their treatment throughout the whole of their career, which may in fact impact on the difficulty they have towards the end of life," Dr Olver told Medscape Medical News.

The decision to treat in the last month of life was highly polarized, and hematologic oncologists were more likely to favor prescribing systemic therapy.

"This study raises a lot of opportunities for further research to standardize practice and understand attitudes and beliefs towards end-of-life care," Dr Hui noted.

"We need to understand more about unrealistic expectations from both patients and doctors," added Dr Olver. "We need to try to communicate so the patient isn't as unrealistic about their outcomes and the balance between potential toxicity and lack of benefit at this stage of the illness. But we also have to realize that there is considerable prognostic uncertainty in these situations."

Dr Hui and Dr Olver have disclosed no relevant financial relationships.

Multinational Association of Supportive Care in Cancer (MASCC) Annual Meeting. Abstract 17-04-O. Presented June 26, 2015.

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