Palliative chemotherapy and travel distance impacts hospice referral in patients with stage IV pancreatic cancer.

Abstract

490 Background: Despite advances in chemotherapy (CTx), the prognosis for metastatic pancreatic ductal adenocarcinoma (mPDAC) is poor and while hospice is known to improve end-of-life care, referrals are often placed close to death. This may be due to accessibility issues or misconceptions that referral implies abandonment. We hypothesized that utilization of palliative CTx and travel distance to the treatment center impacts hospice referral patterns. Methods: Patients with histologically confirmed or radiographically presumed mPDAC as their initial diagnosis were retrospectively identified in a Veterans Administration Medical Center (VAMC) from 2005-2014. Demographic and clinical data were collected according to timing of hospice referral. Results: Fifty-eight mPDAC patients were identified with a median age of 63yr of which 57 (98.3%) were male. Palliative CTx was used in 26 (44.8%) patients with 32 (55.2%) not treated due to poor performance status (n = 18; 56.3%) or patient refusal (n = 14; 43.8%). Of the 52 (89.7%) patients referred to hospice, the median time from diagnosis to referral and referral to death was 2.4wk (Interquartile Range [IQR] 14.9) and 3.1wk (IQR 6.5), respectively. The median time to hospice referral was 18.7wk for patients treated with CTx vs 1.4wk for those who did not undergo therapy (p < 0.001). The median distance from residence to the VAMC was 58.5mi (IQR 77). Subset analysis for those living > 60mi vs < 60mi to the VAMC, the median time to hospice referral was 1.7wk vs 4.7wk, respectively (p = 0.1). With no significant differences between groups in age, sex, race, or disease burden, univariate analysis demonstrated that those referred to hospice > 2.4wk from diagnosis more often received CTx (p < 0.001) and lived > 60mi from the treatment center (p = 0.05). Conclusions: The majority of patients with mPDAC were enrolled in hospice and while travel distance trended to shorter time to referral, this was not significant. However, receipt of palliative chemotherapy did delay referral and those with this delay lived farther from the hospital. These data suggest that physicians delay hospice care in patients who are able to tolerate treatment and travel long distance to receive it.