| Description |
- Background: Metastatic breast cancer (MBC) is incurable, despite recent therapeutic advances resulting in extended trajectories of disease, especially in estrogen receptor positive (ER+) and human epidermal growth factor-2 negative (HER2-) MBC. Palliative care (PC) is recommended to alleviate distress of advanced cancer and reduce receipt of aggressive care at the end-of-life (EoL). Intensive EoL care is associated with greater physical and emotional distress of patients and caregivers. Validated indicators of overly aggressive EoL care include repeated hospitalizations and emergency department (ED) visits or intensive care unit (ICU) admission in the last 30 days of life; chemotherapy administration within the last 14 days of life; absence of hospice enrollment or short hospice duration; and in-hospital location of death. The aim of this study was to describe PC and hospice utilization and EoL outcomes, including rate of aggressive EoL care, in patients with ER+/HER2- MBC.
Methods: A retrospective review was performed of patients with ER+/HER2- MBC treated with endocrine therapy and/or cyclin-dependent kinase 4 and 6 inhibitors for first-line metastatic disease at Duke Cancer Institute between January 2012 and December 2017. Data extracted from the electronic medical record included demographic and clinical characteristics at time of MBC diagnosis as well as PC use and EoL care. Variables pertaining to PC involvement, hospice enrollment and duration, and EoL care outcomes, including location of death, healthcare utilization in the last 30 days of life, and chemotherapy in the last 30 and 14 days of life, were abstracted through March 15, 2024. PC and hospice utilization and EoL care data were analyzed with descriptive statistics.
Results: Of 102 patients in the cohort, 85 died during the study period, 77 of whom had complete EoL care data, and over half (55%) received aggressive EoL care. Half of the cohort received some form of PC, and among the deceased, rates of aggressive EoL care were comparable between those who engaged with PC (53%) and those who did not (56%). Of those who received PC, in-hospital referrals were more common (61%) than ambulatory referrals (37%), and similar proportions engaged with PC in outpatient clinics (55%) as those with exclusively inpatient PC encounters (45%). Median number of outpatient PC visits was 2 (range 1 – 16 among deceased). Among the indicators of aggressive EoL care, multiple ED visits (28%) and hospital admissions (23%) in the last 30 days of life as well as in-hospital location of death (24%) were the most common. Chemotherapy was administered within the last 30 days for 16 patients (20%) and within the last 14 days of life for 9 patients (11%). Although 72% enrolled in hospice, 9% were on hospice for ≤ 3 days. Of the 15 patients with durations on hospice greater than 3 days who received aggressive EoL care, most had multiple ED visits and/or hospital admissions in the last 30 days of life.
Conclusions: This real-world study demonstrates that many patients with ER+/HER2- MBC receive aggressive care at EoL despite some engaging with PC and many enrolling in hospice. PC involvement did not appear to impact receipt of aggressive EoL care. This lack of impact of PC on EoL care intensity may be the result of low rates of outpatient PC observed and the median number of outpatient PC visits of only 2, representing insufficient PC “dosage” to facilitate the complex symptom management and advance care planning required to reduce aggressive EoL care that is generally not aligned with most patients’ goals. Interventions to enhance PC engagement and decrease aggressive EoL care are needed to reduce in-hospital deaths, frequency of ED visits, hospitalizations, and ICU admissions in the last month of life, and to ensure patients with MBC experience hospice services for sufficient duration to derive meaningful benefit.
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