Not 'Either/Or' but Both: Cancer Therapy and Hospice Care

Roxanne Nelson, RN, BSN

March 28, 2019

For patients with terminal cancer, one of the primary barriers to earlier hospice enrollment has been termed "the terrible choice" of having to give up curative treatments in order to be eligible for hospice care.

This is the stark situation for Medicare beneficiaries in the United States — they cannot receive Medicare hospice benefits and active cancer treatment at the same time — they have to make a choice.

"However, the reality of terminal disease, with prognostic uncertainties and ever-expanding therapeutic modalities that hold possibility of benefit, can often be incongruent with such an either/or model," comments Tracy A. Balboni, MD, MPH, of the Dana-Farber Brigham and Women's Cancer Center in Boston, Massachusetts.

"This reality leaves many patients turning to hospice care only when death is days to a few weeks away, or not at all," she writes in an editorial published online March 28 in JAMA Oncology.

It doesn't have to be so. The editorial accompanies an article that explores an approach in which hospice care is offered while active care continues in what the authors describe as a "both/and" framework.

Such an approach was incorporated into the Comprehensive End-of-Life Care Initiative introduced by the Department of Veterans Affairs (VA) in 2009. This allowed increased use of hospice care by veterans, but they could also receive concurrent active therapy.

The new study, by Vincent Mor, PhD, of Brown University School of Public Health, Providence, Rhode Island, and colleagues, examined the implications.

The results showed that when the availability of hospice care was increased without restricting access to active cancer treatment, patients still received cancer therapy, although medical treatment tended to be less aggressive and costs were significantly lower.

Study Details

The retrospective study included 13,085 veterans who had been newly diagnosed with stage IV non–small cell lung cancer in 113 VA medical centers between 2006 and 2012.

During the first 6 months after diagnosis or until death, 2816 (21.5%) veterans were admitted to an intensive care unit (ICU), and 4188 (32%) underwent aggressive care. Those who were treated in the highest hospice exposure quintile (HEQ) vs the lowest had lower rates of both ICU use (19.3% vs 24.9%) and aggressive medical care (28.3% vs 35.5%).

There was an increase in the receipt of hospice and concurrent care from the lowest HEQ (7.4%) to the highest (17.5%). The use of radiotherapy after initiation of hospice care was more common than the use of chemotherapy, although both were used more frequently in centers in which there was greater hospice care.

Those who received treatment in the highest-HEQ facilities were about one third as likely to experience aggressive treatments in the 6 months after diagnosis compared with patients in the lowest quintile (adjusted odds ratio [AOR], 0.66; 95% confidence interval [CI], 0.53 – .81).

Veterans in the highest HEQ were 22% less likely to be admitted to an ICU than were those in the lowest-quintile VA medical centers (AOR, 0.78; 95% CI, 0.62 – .99). Although the rates of hospital and aggressive care were lower, concurrent cancer treatment and chemotherapy or radiotherapy following entry into hospice were more than twice as common among veterans in the highest HEQ (AOR, 2.28; 95% CI, 1.67 – 3.11) compared with those in the lowest HEQ.

The authors note that they did not observe any statistically significant difference in the odds of survival within 180 days after diagnosis.

The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. Although more than 40% of the patients had died 100 days after receiving their diagnosis, there was still a significant savings per day among those in the highest-quintile facilities (95% CI, −$329 to −$148).

Medicare May Follow Suit

These findings from the VA's experience suggest that this model may improve care quality while reducing costs, Balboni comments in her editorial. Further study is needed to better characterize the quality of medical care and the implications regarding costs, especially in other settings, she adds.

"In that vein, the Centers for Medicare & Medicaid Services in 2016 implemented the Medicare Care Choices Model (MCCM) to test a concurrent disease-modifying and hospice care model and the quality of life and care of terminally ill Medicare beneficiaries," she notes.

"Evaluation of the MCCM is ongoing and holds promise to provide greater clarity as to the feasibility of a both/and model," she adds.

JAMA Oncol. Published online March 28, 2019. Abstract, Editorial

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