Palliative Care Still Underutilized in Hematologic Malignancies

Roxanne Nelson, RN, BSN

October 29, 2019

SAN FRANCISCO — Even though the use of palliative care has been increasing among patients with hematologic malignancies, the rates are still low as compared with patients with solid tumors, according to new findings.

"Palliative care encounters predominantly occurred within days of death and within a hospital setting," said lead author Vinay Rao, DO, a hospice and palliative medicine specialist at Rhode Island Hospital in Providence.  "This was similar among all histologies."

Patients who received palliative care early, defined as more than 30 days before death, spent an average of 22 days in hospice, while those who received palliative care late or not at all spent a median of 9 days in hospice.

Overall, the median time from first palliative care encounter to death was 10 days in the cohort as a whole.

Rao was presenting these data here at Supportive Care in Oncology Symposium.

"Patients with hematologic malignancies often receive aggressive care at end of life," explained Rao, "And often receive more aggressive care than patients with solid tumors."

He noted that studies have shown that early palliative care may improve end-of-life care among patients with solid tumors, but less is known about patients with hematologic malignancies.

Palliative Care Usage Low, Late

For their study, Rao and colleagues looked at the use of "billed" palliative care services (BPCS) in a cohort of Medicare beneficiaries with various hematologic cancers and assessed the impact of early palliative care on the quality of end-of-life care.

They used the linked SEER-Medicare registry to identify 139,191 Medicare beneficiaries who were diagnosed with leukemia, lymphoma, myeloma, myelodysplastic syndrome, or myeloproliferative neoplasms, and who also met the inclusion criteria; these patients all died between 2001 and 2015.

Within this group, 7270 (5.2%) received any palliative care, while only 2013 (1.4%) received early palliative care.

"The frequency of palliative care consults in any group was very low, and we found that most of the encounters happened late," said Rao. "In any group we found that most of the encounters happened in the hospital, with a very small percentage in the office setting — only about 6%."

However, the team also found that the number of patients receiving palliative care services increased "exponentially" over time. The proportion of patients with any BPCS increased from 0.4% in 2001 to 13.3% in 2015.

Among patients with early BPCS, 64% died while in hospice, compared with 47% who did not receive it (P < .001).

An admission to the intensive care unit during the last 30 days of life occurred in 28% who received early BPCS compared to 37% who did not (P < .001).

An inpatient death was also more common in the group that did not receive early BPCS: 38% vs 27% (P < .001).

The authors also looked at the demographics, and if there were differences among patient populations. They found that the use of early BPCS was more frequent in patients with acute leukemia, among black patients, those with higher comorbidity indices or poor performance statuses, and among patients who were receiving chemotherapy.

Another trend they observed was changes in billing by specialty. "In 2000, most claims were made by general and internal medicine," he said. "But over time, we saw a relative decrease in claims from general medicine and an increase in those from nurse practitioners and palliative and hospice medicine."

There were several limitations to this study, Rao pointed out. "One was that it was retrospective, so it shows association and not causation."

ICD codes for "encounters with palliative care," are also not specific for palliative care per se, he pointed out. They can include services like comfort care, end-of-life care, and terminal care while specialty palliative care offers additional skills and services.

"Since causation in retrospective studies is uncertain, these results support the need for prospective trials in this setting," he concluded.

Barriers to Integration

In a discussion of the study, Oreofe O. Odejide, MD, MPH, from the Department of Medical Oncology at Dana-Farber Cancer Institute, Boston, Massachusetts, noted that previous studies have indicated that the intensity of end-of-life healthcare utilization in cancer is high and rising, especially among patients with hematologic malignancies.

This is problematic, she said, because research shows that this high intensity of healthcare utilization at the end of life can cause high physical distress, poor psychological well-being and overall poor quality of life. It can also negatively impact caregivers, she added.

"We all know that early palliative care and hospice are beneficial, and despite the fact that we have evidence to support this, it remains underutilized in cancer," Odejide said. "There has been an increase in hospice enrollment, but for many patients this occurs very late and often in the last few days of life."

This study from Rao and colleagues is an important contribution as it "offers insight into real-world influence of palliative care for hematologic patients, and it has a large sample size and includes multiple subtypes of hematologic cancers," she continued.

However, she pointed out, "It is important to note that viewed claims were used as a proxy for palliative care, and so it's hard to tease apart what aspect of the palliative care encounter impacted care at the end of life — so this sets the stage for future prospective studies."

The key message is that, even though the use of palliative care has increased over time, use remains low and it occurs late, "so there is a lot of work to be done in integrating palliative care into hematologic malignancies," she said.

In order to do that, barriers to care need to be broken down, Odejide stressed.

One of these barriers is that palliative care is end-of-life care, and "that needs to be corrected," she said.

"There is high prognostic uncertainty, which is rising in this era of CAR-T cell therapy, and studies have also shown there is distrust between hematologic oncologists and palliative care specialists," she said.

Solutions include education, as well as prospective randomized trials, Odejide concluded. "We also need to uncouple prognostic certainty from palliative care integration."

The study was funded by the American Cancer Society. Rao has disclosed no relevant financial relationships. Several coauthors report relationships with industry.

Supportive Care in Oncology Symposium (SCOS) 2019: Abstract 43. Presented October 27, 2019.

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