Abstract
Ensuring high quality end of life (EOL) care is necessary for people with advanced non-small-cell lung cancer (NSCLC), given its high incidence, mortality and symptom burden. Aggressive EOL care can adversely affect the quality of life of NSCLC patients without providing meaningful oncologic benefit. Objectives: (1) To describe EOL health services quality indicators and timing of palliative care consultation provided to patients dying of NSCLC. (2) To examine associations between aggressive and supportive care and patient, disease and treatment characteristics. Methods: This retrospective population-based cohort study describes those who died of NSCLC in Ontario, Canada from 2009–2017. Socio-demographic, patient, disease and treatment characteristics as well as EOL health service quality and use of palliative care consultation were investigated. Multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. Results: Aggressive care quality indicators were present in 50.3% and supportive care indicators in 60.3% of the cohort (N = 37,203). Aggressive care indicators decreased between 2009 and 2017 (57.4% to 45.3%) and increased for supportive care (54.2% to 67.5%). Benchmarks were not met by 2017 in 3 of 4 cases. Male sex and greater comorbidity were associated with more aggressive EOL care and less supportive care. Older age was negatively associated and rurality positively associated with aggressive care. No palliative care consultation occurred in 56.0%. Conclusions: While improvements in the use of supportive rather than aggressive care were noted, established Canadian benchmarks were not met. Moreover, there is variation in EOL quality between groups and use of earlier palliative care must improve.
Highlights
When examining end of life (EOL) health service quality indicators according to patient, disease and treatment characteristics, we found that patients who received aggressive care were slightly younger (70.9 versus 72.7 years), were more likely to be male (odds ratio (OR) = 1.21 (95% confidence interval (CI) 1.16–1.26)), less likely to live in urban (OR = 0.59) or suburban (OR = 0.73) environments compared with rural areas, more likely to have chronic obstructive pulmonary disease (OR = 1.05), congestive heart failure (OR = 1.12) or
The number of patients who received aggressive care decreased considerably over the study period (2009–2017) while patients receiving supportive care increased substantially. This is encouraging as it indicates a positive shift in the quality of EOL care offered to patients with non-small-cell lung cancer (NSCLC)
When comparing individual aggressive care indicators to findings from an international comparative study of lung cancer deaths occurring in 2010 among adults >65 years in developed countries [12], we found that the percentage of patients (N = 4467 decedents) who were admitted to an intensive care unit (ICU) within 30 days of death were similar (9.56% versus 8.5%)
Summary
It is estimated that 29,800 Canadians were diagnosed with lung cancer in 2020 and the 5-year net survival rate was 19% [1]. Patients can experience symptoms specific to their disease process (such as chronic cough, dyspnea, or pain) or more generalized symptoms (such as fatigue, loss of appetite, or cachexia). These symptoms can lead to, or exacerbate, psychological symptoms (such as depression and anxiety). Patients with non-small-cell lung cancer (NSCLC) often present with advanced disease and a high symptom burden. These symptoms contribute to distress, suffering and diminished quality of life and require intensive resources. Given the incurable nature of metastatic, unresectable NSCLC, the goals of therapy should include an emphasis on patient-oriented outcomes which optimize quality of life and reduce unnecessarily aggressive end of life (EOL) care and increase supportive EOL care [4,5,6,7,8]
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