Incorrect Survival Prediction Ups Aggressive End-of-Life Care

Still, 75% of Guesses Were Accurate in Study

Pam Harrison

October 23, 2018

SAN ANTONIO — An inability to accurately predict how long patients with metastatic lung cancer have left to live increases the likelihood of aggressive, poor-quality end-of-life care of dubious benefit, new research suggests.

"Previous studies have shown that increased and intensive cancer treatment at the end of life is associated with decreased quality of life for patients, increased costs, and [that such care] often contradicts the wishes of patients and their families," said Katherine Sborov, BA, of the Stanford Cancer Institute in California.

She spoke at session here at the American Society for Radiation Oncology (ASTRO) 2018.

This is why both the National Quality Forum's (NQF's) and the American Society of Clinical Oncology's Quality of Oncology Practice Initiative (QOPI) each developed guidelines that define intensive, poor-quality cancer care at the end of life, Sborov added.

Despite these guidelines, cancer patients continue to receive poor-quality end-of-life care. The list of inappropriate interventions includes advanced radiation techniques, more than one hospital or emergency department visit within the last 30 days of life, and chemotherapy in the last 14 days of life, Sborov noted.

"And we found that 32% of our cohort of patients met at least one NQF/QOPI metric of poor-quality end-of-life care," she reported. Also, as physicians became increasingly inaccurate with their survival predictions, patients were increasingly more likely to receive intensive, poor-quality care.

Sborov and colleagues identified 375 patients for whom there were 468 care-provider encounters involving survival estimates.

Oncologists accurately predicted survival (<12 months) in 363 (77.7%) encounters. In 54 encounters (11.6%), patients were predicted to live 12 to 18 months; in 27 encounters (5.8%), patients were predicted to live 18-24 months; and in 23 encounters (4.9%), patients were predicted to live >24 months.

Survival estimates were more accurate for patients whose Eastern Cooperative Oncology Group (ECOG) performance status was 2 to 4, at 85%, but were less accurate for patients whose ECOG performance status was <2, at 72% (P = .001).

Physicians were more likely to accurately predict survival if the primary cancer was lung cancer (82%) and gastrointestinal cancer (83%), but they were less accurate for cancers of the head and neck or skin (70%). They were also less accurate for breast cancer (68%) and prostate and genitourinary cancer (65%).

Accuracy of survival estimates was not affected by age, race, marital or insurance status, or the presence of brain metastases.

These incorrect predictions led to a substantial proportion of patients receiving some form of inappropriate end-of-life care, as defined by NQF/QOPI metrics.

For example, 12% of patients were hospitalized more than once in the last 30 days of their life.

Fourteen percent of patients died in hospital; 11% received advanced radiation techniques; and, importantly, more than half of the cohort were not referred to palliative care services or did not have an advance directive.

Moreover, compared to patients whose survival predictions were accurate, those who were predicted to live for at least 24 more months were 2.5-fold more likely to have met at least one NQF/QOPI metric for intense end-of-life care (P = .03).

Those who were predicted to survive 18 to 24 months longer than they actually lived were 39% more likely to have met at least one NQF/QOPI metric prior to their death.

"Patients have very strong opinions about what they want their care to be," Sborova told Medscape Medical News.

"Ultimately, it comes down to physician and patient communication about what end-of-life goals are, and because radiation oncologists have this unique position where they can see their patients every day on treatment, they can have a better understanding of what the disease burden is for patients and whether or not people are responding to treatment," Sborova suggested.

Overly Optimistic

If physicians can be excused for being overly optimistic about a terminal cancer patient's chances of survival, they also need to be more mindful of the consequences of offering aggressive end-of-life care for patients and their families.

This point was made starkly apparent by a study presented in the same palliative care session. Jared Robbins, MD, University of Arizona, Tucson, and colleagues detailed just how inappropriate the use of whole-brain radiation therapy (WBRT) is for patients who have non–small cell lung cancer (NSCLC) and brain metastases at the time of diagnosis.

Robbins and colleagues analyzed 14,810 NSCLC patients from the National Cancer Database from 2010 to 2013 who presented with brain metastases on initial diagnosis.

Fractionation regimens compatible with WBRT included 200 cGY/fraction, for a total of 40 Gy in 20 fractions; 250 cGy/fraction, for a total of 37.5 Gy in 15 fractions; 300 cGY/fraction, for a total of 30 Gy in 10 fractions; and 400 cGY/fraction, for a total of 20 Gy in five fractions.

"Almost all patients, at 98% of the cohort, were offered at least 10 fractions, and only 2% had a shorter course of treatment," Robbins told Medscape Medical News.

He added that this may explain why only 84% of all WBRT patients completed the full therapeutic course

Median overall survival was only 4.85 months.

The investigators then estimated the percentage of remaining life spent receiving WBRT, which was calculated as elapsed days of WBRT from start of WBRT to death.

Results showed that 14% of the cohort died within 30 days of starting WBRT and that 36% of the patients died within 60 days of completing WBRT, assuming a standard 10-day course.

Moreover, 28% of the group spent at least one quarter of the remaining time in their life receiving WBRT, and 12% of the group overall spent at least half of their remaining days receiving WBRT.

A significant proportion of patients (25% to about 50%, depending on the fractionation) also received chemotherapy after undergoing WBRT, said Robbins.

"If people die close to radiation or if they stop the radiation, they are not deriving any benefit from it," Robbins observed.

"So regardless of the dose-fractionation used, receiving and recovering from WBRT often occupies a substantial portion of their remaining life, and for NSCLC patients with brain metastases at diagnosis, serious consideration should be given to supportive care alone or 20 Gy in five fractions," he concluded.

Also commenting on the findings, lead author Shayna Rich, MD, PhD, told Medscape Medical News that there is a subgroup of NSCLC patients with brain metastases for whom WBRT would be beneficial.

Typically, these are patients who are likely to have a relatively good prognosis and who still have good cognition.

"I think it's natural when you are faced with a patient that you want to be optimistic, but the problem is that we sometimes fail to see the downside, where patients lose their ability to have more time at home or with their family, and we need to consider this issue when we are prescribing a treatment," Rich said.

Main Issues

Asked by Medscape Medical News to comment on the palliative care findings, Robert Miller, MD, professor of radiation oncology, Mayo Clinic, Jacksonville, Florida, noted that in both studies, two main issues are at stake, one regarding patients and the other economics.

Miller insisted that from a patient's perspective, it is critical that physicians incorporate the patienet's needs and wants into the treatment plan.

"People also now realize that intervening early to care for symptoms allows patients to benefit from an improved quality of life, and if you can help them with their basic needs, such as pain or nutrition, they may not want as intense a therapy as they would pick if their symptoms are unrelieved," Miller stressed.

"So if patients are predicted to not have a long survival, not to intervene in intensive ways, such as not offering chemotherapy and immunotherapy, is one way we can drive down hospital-associated costs near the end of life, if that's what the patient wants," he added.

Katherine Sborov has disclosed no relevant financial relationships. Dr Robbins has received travel expenses from Elekta KV. Dr Rich and Dr Dharmarajan have disclosed no relevant financial relatioships. Dr Miller has received travel expenses from Curtis Pharma.

American Society for Radiation Oncology (ASTRO) 2018. Abstract 1017 1011, presented October 21, 2018

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