US Hospices Offering Less Palliative Chemotherapy and Radiation

By Lisa Rapaport

May 16, 2020

(Reuters Health) — U.S. hospices have cut back on palliative chemotherapy and radiation in recent years, according to an analysis of cost reports.

The move is in line with recommendations against systemic chemotherapy at the end of life, but may also prompt some patients to postpone hospice to get needed radiation, the study authors conclude in JAMA Oncology.

Researchers used 2011-2019 Hospice Cost Report Data that covers freestanding hospices in the U.S. from 2011 through 2018 to calculate expenses for chemotherapy and radiation. The number of Medicare-certified freestanding hospices climbed from 2,404 hospices in 2011 to 2,948 by 2018. Over this same period, hospices decreased radiotherapy expenses by 75% and chemotherapy expenses by 90%.

While the declining use of palliative chemotherapy reflects a growing recognition that this isn't needed at the end of life, the results suggest that many hospice patients may be missing out on palliative radiotherapy that might make their final days more comfortable, said study coauthor Dr. Shi-Yi Wang of Yale Cancer Center in New Haven, Connecticut.

"Chemotherapy in the last 14 days is considered as aggressive end of life care, and is generally not consistent with patients' preferences," Dr. Wang said by email. "Given the toxicity of chemotherapy, the harms outweigh the benefits."

Radiotherapy is a different story, however.

"Palliative radiotherapy can reduce pain and symptoms, such as radiotherapy for bone metastasis - and the side effects of radiotherapy are minor," Dr. Wang said. "Symptom relief can improve quality of life for these patients."

Total expenses for freestanding hospices surged during the study period, from $1.2 billion in 2011 to $15 billion in 2018.

Over this timeframe, chemotherapy expenses declined from $12.3 million to $1.3 million, and the number of hospices with chemotherapy expenses declined from 113 (4.7%) to 92 (3.1%).

Radiation expenses also decreased, from $6.3 million to $1.3 million, while the number of hospices with radiotherapy expenses dropped from 307 (12.8%) to 159 (5.4%).

Mean monthly chemotherapy expenses among nonprofit hospices that provided chemotherapy plunged from $17,029 in 2011 to $2,322 in 2018. Mean monthly radiation expenses also dropped among hospices that offered this intervention.

One limitation of the study is that results from freestanding hospices can't be generalized to hospital-affiliated hospices, the study team notes. They were also unable to calculate chemotherapy and radiation expenses per patient with cancer.

In addition, the researchers were unable to determine what factors may have contributed to decreases in chemotherapy and radiotherapy at hospices.

"Few conclusions can be drawn from the data presented, although the study does highlight the need for improved tracking of palliative cancer therapies in U.S. hospices and further investigation into the drivers of treatment utilization," said Dr. Emily Martin, a palliative care physician at the David Geffen School of Medicine at University of California, Los Angeles.

"One of the main take-aways is that tax exempt status continues to be a key factor in whether or not a hospice provides palliative therapies," Dr. Martin, who wasn't involved in the study, said by email.

Still it's not uncommon that a patient or family will have to choose between a patient receiving palliative treatment for their cancer or enrolling in hospice, said Dr. James Murphy, an associate professor in radiation medicine at the University of California, San Diego.

"In reality, patients could very likely benefit from both palliative treatment and hospice at the same time, yet reimbursement constraints tie the hands of our patients," Dr. Murphy, who wasn't involved in the study, said by email.

SOURCE: JAMA Oncology, online April 30, 2020.