Receipt Of Palliative Care Research Articles

Patient-Reported and End-of-Life Outcomes Among Adults with Oncogene-Driven Lung Cancer in a Clinical Trial of Early Integrated Palliative Care: A Secondary Analysis (F415C)

1.Distinguish the quality of life, symptom experience, illness understanding and end-of-life outcomes of patients with oncogene-driven NSCLC from those of patients with wild-type NSCLC in order to identify differences in the experience of patients who benefit from highly effective therapy in the setting of life-limiting cancer compared to patients who receive chemotherapy.2.Translate the findings of this analysis into opportunities to tailor palliative care for patients with life-limiting cancer who benefit from highly effective cancer-directed therapy. Targeted therapy has revolutionized treatment for patients with oncogene-driven non-small cell lung cancer (NSCLC), though data are lacking on patient-reported and end-of-life (EOL) care outcomes in this population. The goal of this study was to compare quality of life (QOL), symptoms, illness understanding and EOL care between patients with oncogene-driven versus wild-type NSCLC. In this secondary analysis of a randomized controlled trial of early integrated palliative and oncology care in patients with advanced NSCLC, we compared change in QOL and symptoms (per the Functional Assessment in Cancer Treatment [FACT]-General and Lung Cancer Subscale [LCS]) over 24 weeks among patients with oncogene-driven versus wild-type NSCLC using linear mixed effects models adjusted for receipt of palliative care. We also compared patients’ self-reported prognostic understanding and decedents’ EOL health care utilization using logistic regression. Compared to individuals with wild-type NSCLC, patients with oncogene-driven NSCLC reported significantly greater improvements in QOL (B=4.84; 95% CI 1.70, 7.99 for FACT-General) and symptoms (B=1.28; 95% CI 0.29, 2.26 for LCS) over time, independent of palliative care. Patients with oncogene-driven NSCLC were less likely to discuss prognosis with their clinicians (OR 3.49; p=0.016 for reporting "never” or "rarely” discussed prognosis), more likely to report that their treatment was curative (OR 2.24; p=0.05), and more likely to receive chemotherapy in the last 14 days of life (OR 5.33; p=0.036) than patients with wild-type NSCLC. Patients with oncogene-driven NSCLC experience marked improvements in QOL and symptoms relative to those with wild-type NSCLC, likely due to disease control by targeted therapy. They are also less likely to discuss their prognosis with oncology clinicians, which may contribute to intensive EOL treatment.

Factors associated with palliative care (PC) utilization in advanced and metastatic renal cell carcinoma (RCC).

297 Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC. Results: We identified 20,122 and 42,014 patients with stage III and IV RCC, respectively. Among this cohort, 329 and 9,317 patients received PC for stage III and IV RCC, respectively. From 2004 to 2014, PC utilization has been stable at ~1% for stage III RCC and has significantly increased from 17% to 20% for stage IV RCC. Multivariable analysis demonstrated that Blacks, income >$48,000, regions outside of Northeast, stage III RCC, and patients that received surgery were less likely to receive PC. Patients that were female, with more comorbidities, uninsured or with government insurance, lower educational status, treated at academic or integrated cancer program, with sarcomatoid histology, receiving systemic therapy were more likely to receive PC. Conclusions: While PC utilization has significantly increased for stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC usage among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

Patient-Reported and End-of-Life Outcomes Among Adults With Lung Cancer Receiving Targeted Therapy in a Clinical Trial of Early Integrated Palliative Care: A Secondary Analysis

ContextTargeted therapy has revolutionized lung cancer treatment and markedly increased survival, though data are lacking on patient-reported and end-of-life (EOL) outcomes among patients receiving targeted therapy. ObjectivesThis study aimed to compare quality of life (QOL), symptoms, prognostic communication, and EOL care between patients receiving targeted therapy and patients with lung cancer without targetable mutations. MethodsIn this secondary analysis of a randomized trial of early palliative care in advanced lung cancer (n=154), we compared change in QOL and symptoms (per the Functional Assessment of Cancer Treatment [FACT]-Lung scale) over 24 weeks among patients with lung cancer receiving targeted therapy versus those without targetable mutations using linear mixed effects models, adjusted for receipt of palliative care, age and gender. We also compared prognostic communication and decedents’ EOL health care utilization using logistic regression, adjusted for palliative care. ResultsCompared to individuals without targetable mutations, patients receiving targeted therapy (n=35) reported greater improvements in QOL (FACT-General B=0.46; 95% CI=0.19, 0.73) and symptoms (FACT-Lung Cancer Subscale B=0.12; 95% CI=0.03, 0.20) over time, independent of palliative care. Patients receiving targeted therapy were also more likely to report they rarely discussed prognosis with their clinicians (OR=2.59, 95% CI=1.01, 6.63) and were more likely to receive cancer-directed therapy in their last 14 days of life (OR=14.98, 95% CI=4.08, 54.96). ConclusionsRelative to patients without targetable mutations, patients with lung cancer who receive targeted therapy experience improved QOL and symptoms, are less likely to discuss prognosis early in their illness course, and more likely to continue treatment until death and die in the hospital.

Cost Savings Associated With Palliative Care Among Older Adults With Advanced Cancer.

There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients. We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation. Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643. This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma

Abstract PR03: Racial and health care access disparities in palliative care receipt among patients with advanced non-small cell lung cancer: An analysis of the 2016 National Cancer Database

Abstract Background: Early intervention with palliative care (PC) improves quality of life and increases survival among patients with advanced-stage non-small cell lung cancer (aNCSLC). However, PC is often offered late in the cancer care continuum and is underused. Few studies have examined racial disparities or evaluated the role of access to care in PC use among diverse aNCSLC patients. Objective: To determine the prevalence of PC use among aNSCLC patients by race/ethnicity and assess the role of healthcare access in PC disparities Methods: We used data from the 2004-2016 National Cancer Database, including adults aged 18-90 years with aNSCLC (stage 3 or 4 at diagnosis) who were deceased based on vital status on last contact (n=803,618). Based on the NCCN guidelines, PC includes surgery, radiation, chemotherapy, pain management or any combination with non-curative intent. We examined PC utilization rates by sociodemographic and health care access characteristics, and estimated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using logistic regression to evaluate the independent associations of race/ethnicity and health care access with PC. Covariate adjustment sets for racial disparities and health care access factor analyses varied by exposure determined using directed acyclic graphs. Results: Our population was 55% male and 77% NH-White, with a mean age of 68 years. Overall, 20% of aNSCLC patients received any PC, while 6% received pain management. Compared to non-Hispanic (NH)-White patients, NH-Black (aOR: 0.91, 95% CI: 0.90-0.93) and Hispanic patients (aOR: 0.80, 9%% CI: 0.77-0.83) were less likely to receive PC after adjustment for socio-demographic and clinical variables. However, American Indian/Alaskan Native (aOR: 1.12, 95% CI: 1.01-1.24) and Native Hawaiian/Pacific Islander (aOR: 2.04, 95% CI:1.79-2.33) were significantly more likely to receive PC. Overall, compared to privately insured patients, uninsured patients (aOR: 1.14, 95% CI: 1.10-1.17) and Medicaid patients (aOR: 1.16, 95% CI: 1.14-1.19) were more likely to receive PC, while patients treated at a community cancer program (aOR: 0.89, 95% CI: 0.87-0.91) were less likely to receive PC compared with those treated at Comprehensive Cancer programs. Treatment at an integrated network cancer program was associated with increased likelihood of PC use (aOR: 1.12, 95% CI: 1.11-1.14). When stratified by race/ethnicity, the associations between healthcare access and PC utilization was consistent across race/ethnic groups. Notably, Asian patients were more likely to receive PC at all types of cancer treatment facilities compared to NH-White patients. Conclusion: NH-Black and Hispanic patients with aNSCLC are less likely to receive palliative care, a disparity that may be associated with insurance type and type of cancer treatment facility. Strategies to enhance palliative care utilization among underserved patients with aNSCLC should be identified in order to improve quality of life and survival. Citation Format: Jessica Y. Islam, Dejana Braithwaite, Dongyu Zhang, Tina D. Tailor, Tomi Akinyemiju. Racial and health care access disparities in palliative care receipt among patients with advanced non-small cell lung cancer: An analysis of the 2016 National Cancer Database [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PR03.

Inequalities in end-of-life palliative care by country of birth in New South Wales, Australia: a cohort study.

Objective This study investigated variation in in-hospital palliative care according to the decedent's country of birth. Methods A retrospective cohort study was performed of 73469 patients who died in a New South Wales public hospital between July 2010 and June 2015 and were diagnosed with a palliative care-amenable condition. Differences in receipt of palliative care by country of birth were examined using multilevel logistic regression models adjusted for confounding. Results In this cohort, 26444 decedents received palliative care during their last hospital stay. In the adjusted analysis, 40% rate differences (median odds ratio 1.39; 95% confidence interval 1.31-1.51) were observed in receipt of palliative care between country of birth groups. Conclusions There are differences in in-hospital palliative care at the end of life between population groups born in different countries living in Australia. The implementation of culturally sensitive palliative care programs may help reduce these inequalities. Further studies are needed to identify the determinants of the differences observed in this study and to investigate whether these differences persist in the community setting. What is known about the topic? International studies have reported inequities in access to palliative care between ethnic groups. What does this paper add? We observed differences in in-hospital palliative care between decedents from different countries of birth in New South Wales, Australia. These differences remained after adjusting for individual, area and hospital characteristics. What are the implications for practitioners? Implementation of culturally sensitive palliative care services and targeting groups with low rates of palliative care can reduce these inequalities and improve a patient's quality of life.

Frequency and Timing of Palliative Opportunities in Pediatric Patients with Hematologic Malignancies

Background: Due to relatively more favorable survival rates, parents and providers of children with hematologic malignancies maintain high hopes for cure, resulting in more cure-directed therapy and hospitalizations at the end-of-life (EOL), as well as delayed palliative care (PC) involvement. Pediatric patients with hematologic malignancies are less likely to receive PC and die at home versus patients with solid tumors, and often undergo intensive EOL care. Despite favorable prognoses, patients still relapse and experience other challenging events throughout their disease. A "palliative opportunity" is an event during a patient's disease course at which time subspecialty PC, or care provided by clinicians with subspecialty training or board certification in PC, could be provided to improve the overall care of the patient or family. It is important to explore palliative opportunities to better understand the disease course, as well as how and when to introduce PC to patients and families. Objectives: Examine the palliative opportunities present during a patient's course with a hematologic malignancy and relevant demographic, disease, or EOL associations. Methods: A single-center retrospective review was conducted on patients aged 0-18 years with leukemia or lymphoma who died from 1/1/12-11/30/17. Demographic, disease, and treatment data were collected. A priori, nine palliative opportunity categories were defined: (1) relapse of disease, (2) disease progression, (3) receipt of bone marrow transplant (BMT) or chimeric antigen receptor T-cell (CAR-T) therapy, (4) Phase 1 trial enrollment, (5) admission for symptoms (pain or dyspnea requiring IV opioids, nausea/vomiting requiring IV anti-emetics, fatigue, neurologic symptoms, or social concerns), (6) intensive care unit (ICU) admission, (7) admission for EOL care, (8) hospice enrollment, (9) do-not-resuscitate (DNR) status. Opportunities were evaluated overall and temporally over quartiles from diagnosis to death, independent of PC consultation. Descriptive and inferential statistics were performed using SAS Enterprise Guide 7.1. Results: During the study period, 92 patients with hematologic malignancies died, including 55 with B or T-cell lymphoid leukemia/lymphoma, 33 with acute/chronic myeloid leukemia, and 4 with Hodgkin/Non-Hodgkin lymphoma. These patients incurred 522 total opportunities with a median of 5.0 (Interquartile Range (IQR)=6.0) palliative opportunities per patient throughout their disease course. The majority of opportunities occurred in the last quartile of the disease course. Of the 522 opportunities, 64.9% occurred prior to or without PC support. Except for religion (p=0.0002), number and type of opportunities did not differ by demographics. 44 patients (47.9%) received PC consultation, occurring a median of 1.8 months (IQR=4.1) prior to death. PC consultation was most common in patients with lymphoid leukemia (63.6%) vs myeloid leukemia (36.4%) or Hodgkin/Non-Hodgkin lymphoma (0%, p=0.14). Receipt of PC was associated with BMT status and a higher number of palliative opportunities (p=0.0018 and p=0.0005, respectively). The most common documented reason for PC consultation was disease-related relapse or progression (30, 68.2%), followed by EOL (7, 15.9%), and symptom management (7, 15.9%). The palliative opportunities that immediately preceded PC consultation were most commonly ICU admission (15, 34.1%), relapse (8, 18.2%), disease progression (6, 13.6%), and DNR order placement (5, 11.4%). Patients who received PC consultation were more likely to have also enrolled in hospice (19/44, 43.2%) compared to those that did not receive PC consultation (6/48, 12.5%, p=0.001). Conclusion: Patients with hematologic malignancies experience many events warranting PC support, which increase toward the EOL. However, less than half of patients in this cohort received PC consultation, and often late in their disease course. This demonstrates potential missed opportunities for discussion of goals of care or improving quality of life through relief of physical, psychological, and psychosocial symptoms. The integration of PC into cancer care improves symptom management, emotional and psychosocial wellbeing, and EOL decisions. Defining palliative opportunities together with the disease program helps identify ideal timing and candidates for PC involvement. Disclosures No relevant conflicts of interest to declare.

Impact of Hospital Volume on Mortality for Brain Metastases Treated with Radiation

BACKGROUND: The impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases. MATERIALS AND METHODS: Analysis was conducted using the National Cancer Database (NCDB) from 2010–2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5–11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model. RESULTS: A total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care. CONCLUSION: Hospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population.

Palliative care referral patterns and measures of aggressive care at the end of life in patients with cervical cancer

IntroductionFifteen per cent of women with cervical cancer are diagnosed with advanced disease and carry a 5 year survival rate of only 17%. Cervical cancer may lead to particularly severe...

The impact of routine Edmonton symptom assessment system use on receiving palliative care services: results of a population-based retrospective-matched cohort analysis

BackgroundIn 2007, Cancer Care Ontario began standardised symptom assessment as part of routine care using the Edmonton Symptom Assessment System (ESAS).AimThe purpose of this study was to evaluate the impact...

Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study

Background: Providing equitable care to patients in need across the life course is a priority for many healthcare systems. Aim: To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). Design: Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). Setting/Participants: A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. Results: In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9–5.1%), which was 8.6% (6.2–10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8–7.8%) absolute gap, 26.3% (22.5–30.0%) relative gap) and for physician encounters (6.8% (5.7–7.9%) absolute gap, 13.2% (11.0–15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). Conclusion: Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.

A Lack of Palliative Therapy Use in Patients With Advanced Penile Cancer.

Advanced penile cancer is associated with a poor prognosis; therefore, providing patients with realistic expectations, addressing goals of care and offering palliative therapy when appropriate is critical. Our goal was to investigate the National Cancer Database (NCDB) and analyze the role and trends in use of palliative therapy in patients with advanced penile cancer. The NCDB 2004-2015 penile cancer data set was queried for patients with locally advanced, defined as cT4NanyM0 and cTanyN3M0, or metastatic disease regardless of tumor or nodal stage. Patients were categorized based on whether they did or did not receive palliative care. Palliative care was cataloged as pain management therapy, surgery, radiation or systemic treatment, any combination therapy or not otherwise specified (NOS). Our primary outcome was receiving palliative therapy. Secondary outcome was the temporal trends in palliative care. Logistic regression (LR) was performed. 385 and 279 patients were identified with locally advanced and metastatic penile cancer respectively. 27 (7.1%) and 49 (17.6%) patients received palliative care. Average age of patients accepting palliative care was 61.9 years old, about 5 years younger than their counterparts who declined therapy (p < 0.011) in the metastatic cohort. Other patient specific demographics and clinical tumor characteristics were not significantly different in either population. Of patients with locally advanced disease pursuing palliative therapy, radiation (29.6%), surgery (14.8%), systemic treatment (14.8%) and combination treatment (22.2%) were the more popular choices. In the metastatic population, radiation (32.7%) and systemic therapy (24.5%) were the most prevalent choices for palliative treatment followed by combination treatment (16.3%), surgery (12.2%), pain management (10.2%), or NOS (4.1%). LR for the receipt of "any palliative therapy" revealed that increasing age (OR 0.971, p = 0.032) decreased the likelihood of accepting palliative therapy in the metastatic population but not in the locally advanced group. Charlson score of 2 (OR 5.966, p = 0.025) and low income (OR 3.968, p = 0.002) predicted receipt of palliative therapy in the locally advanced group. In patients with metastatic disease, African-American race (OR 2.502, p = 0.025), Charlson score 1 (2.175, p = 0.047) and 3+ (5.386, p = 0.020) predicted an increased predilection for receiving palliative therapy. Interestingly, no statistically significant difference in mortality was noted in either cohort. No significant increase in the trend of palliative care administration was seen in locally advanced and metastatic penile cancer between 2004 to 2015 (p = 0.078 and p = 0.942, respectively). Locally advanced and metastatic penile cancer carry a high mortality rate yet only 11.4% of all patients studied received palliative care. Its use is more common in younger patients, those with co-morbidities and/or those of black race in the metastatic group. Locally advanced patients with low income or comorbidities were also more likely to opt for palliative therapy. Receipt of palliative care did not affect mortality. No increase in frequency of palliative therapy was seen, suggesting much improvement needs to be done in adopting and implementing palliative care in this patient population.

Underutilization of Palliative Care in Metastatic Foregut Cancer Patients Is Associated with Socioeconomic Disparities

BackgroundMetastatic foregut cancers (MFC) are associated with debilitating symptoms that negatively impact patients’ quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects and may improve survival in select cases. Our study characterizes PC utilization rates in MFC and identifies factors associated with PC receipt. MethodsWe conducted a retrospective review of 228,027 National Cancer Database patients diagnosed with MFC between 2004 and 2016. Chi-squared tests were used to analyze differences between groups receiving and not receiving PC. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. ResultsOverall PC utilization was low (17.8%). A greater proportion of patients not receiving PC were in the lowest median income quartile of < $38,000/year versus those receiving PC (18.1% vs 17.8%, p < 0.0001). Higher education was associated with increased likelihood of receiving PC (OR 1.23 for communities with < 6.3% no high school degree vs ≥ 17.6%, p < 0.0001). Hispanics were significantly less likely to receive PC compared to Whites (OR 0.72, 95% CI 0.68–0.76). Patients treated at academic centers were also more likely to receive PC compared to those treated in the community (OR 1.10, 95% CI 1.05–1.14). ConclusionsPC is a key component in improving quality of life among MFC patients. Despite slight increases in PC rates over time, PC remains drastically underutilized. Significant racial and socioeconomic disparities in patterns of PC delivery exist. Further studies are needed to understand these disparities in order to identify key targets for interventions aimed at improving equity.

Abstract C006: Underutilization of palliative care in metastatic foregut cancer patients is associated with socioeconomic disparities

Abstract Introduction: Metastatic cancers of the foregut are frequently associated with debilitating symptoms that negatively impact quality of life. We aim to determine the rate of palliative care (PC) use in metastatic neoplasms of the foregut and the factors which are associated with receipt of PC. Methods: Using the National Cancer Database (NCDB), patients with metastatic cancers of the foregut were selected. Receipt of PC as defined by the NCDB participant use file was correlated to demographic and clinicopathologic factors. PC treatment included surgery, radiation, systemic therapy, and pain management to alleviate symptoms. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Results: Between 2004 and 2013, 277957 patients with metastatic foregut cancers (MFC) including gastric (42626, 15.3%), pancreas (109219, 39.2%), bile duct (8890, 3.2%), gall bladder (10058, 3.6%) and esophagus cancer (107164, 38.6%) were identified. Median age was 66 years (IQR: 55-76 years) and 64% were male. Among all cancer types, PC utilization was 14.7% (40787). PC utilization increased over time (2004-6 12.3%, 2007-10 14.7%, 2011-13 16.4%; p&amp;lt;0.001). PC utilization was different between cancer types [gastric 6965 (16.3%), pancreas 18814 (17.2%), bile duct 1922 (21.6%), gall bladder 1593 (15.8%) and esophagus cancer 11493 (10.7%)]. There were differences in types of PC interventions utilized in the entire group: surgery 6569 (16.1%), radiation 6964 (17.1%), systemic therapy 12951 (31.8%), pain management 5100 (12.5%) and combination therapy 9203 (22.6%). Factors associated with PC on univariate analysis included sex, race, insurance status, median income, education level, Charlson/Deyo comorbidity score, and year of diagnosis (all p&amp;lt;0.01). On multivariate analysis, female gender (1.09, 95% CI: 1.06-1.11), higher education level (Level 4: 1.36, 95%CI: 1.31-1.42), higher Charlson/Deyo Score (Score: 2: 1.28, 95%CI: 1.23-1.32), and a later year of diagnosis (2011-2013: 1.39, 95%CI: 1.35-1.43) were associated with greater receipt of PC. Furthermore, older patients (75+ years: 0.90, 95%CI: 0.85-0.96), HS race (0.78, 95%CI: 0.74-0.82), private insurance (0.80, 95%CI: 0.76-0.85) and higher income (0.78, 95%CI: 0.75-0.81) were associated with less receipt of PC. Overall survival for the entire cohort is poor at 4.45 months (p&amp;lt;0.001) for the PC group and 6.60 months (p&amp;lt;0.001) for the no PC group. Conclusion: Although PC use has increased over time, it remains underutilized in MFC. Disparities exist in receipt of PC in regard to age, race, gender, insurance status, education, comorbidities and year of diagnosis. Additional research is necessary to better optimize PC use in metastatic cancers of the foregut and mitigate potential disparities. Note: This abstract was not presented at the conference. Citation Format: Michelle Ju, Subhadeep Paul, Adam Yopp, Sam Wang, Matthew Porembka. Underutilization of palliative care in metastatic foregut cancer patients is associated with socioeconomic disparities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C006.

MP76-06 A NATION-WIDE ANALYSIS OF PALLIATIVE CARE USE IN PATIENTS WITH METASTATIC PENILE CANCER

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer III (MP76)1 Apr 2020MP76-06 A NATION-WIDE ANALYSIS OF PALLIATIVE CARE USE IN PATIENTS WITH METASTATIC PENILE CANCER Facundo Davaro*, Allison May, Johar Syed, Sameer Siddiqui, and Zachary Hamilton Facundo Davaro*Facundo Davaro* More articles by this author , Allison MayAllison May More articles by this author , Johar SyedJohar Syed More articles by this author , Sameer SiddiquiSameer Siddiqui More articles by this author , and Zachary HamiltonZachary Hamilton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000962.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Advanced penile cancer is associated with a poor prognosis; therefore, providing patients with realistic expectations, addressing goals of care and offering palliative therapy when appropriate is critical. Our goal was to investigate the National Cancer Database (NCDB) and analyze the role and trends in use of palliative therapy in patients with metastatic penile cancer. METHODS: The NCDB 2004−2015 penile cancer dataset was queried for patients with metastatic disease regardless of tumor or nodal stage. Patients were categorized based on receipt of palliative care. Palliative care was catalogued as pain management therapy, surgery, radiation or systemic treatment, any combination therapy or not otherwise specified (NOS). Our primary outcome was receiving palliative therapy. Secondary outcome was the temporal trends in palliative care. Logistic regression (LR) was performed. RESULTS: 279 patients were identified with metastatic penile cancer with 49 (17.6%) of those receiving palliative care. Average age of patients accepting palliative care was 61.9 years old, about five years younger than those who declined therapy (p <0.011). Other patient specific demographics and clinical tumor characteristics were not significantly different between the two cohorts. Radiation (32.7%) and systemic therapy (24.5%) were the most prevalent choices for palliative treatment followed by combination treatment (16.3%), surgery (12.2%), pain management (10.2%), or NOS (4.1%). LR for the receipt of “any palliative therapy” revealed that increasing age (OR 0.971, p=0.032) decreased the likelihood of accepting palliative therapy. Meanwhile, African-American race (OR 2.502, p=0.025), Charlson score 1 (2.175, p=0.047) and 3+ (5.386, p=0.020) predicted an increased predilection for receiving palliative therapy. No statistically significant difference in mortality was noted between cohorts. No significant increase in the trend of palliative care administration was seen between 2004 to 2015 (p=0.942). CONCLUSIONS: Metastatic penile cancer carries a high mortality rate yet only 17.9% of patients receive palliative care. Its use is more common in younger patients, those with co-morbidities and/or those of black race. Receipt of palliative care did not increase mortality. No changes in the frequency of use were seen. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1153-e1153 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Facundo Davaro* More articles by this author Allison May More articles by this author Johar Syed More articles by this author Sameer Siddiqui More articles by this author Zachary Hamilton More articles by this author Expand All Advertisement PDF downloadLoading ...

Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - 'Safeguarding the Family' study.

Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi. Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis. Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient's death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen's f 2=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income. Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting. Conclusions: This study will provide data on expenditure for healthcare by households affected by advanced cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.

Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - ‘Safeguarding the Family’ study

Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi. Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis. Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient’s death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen’s f 2=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income. Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting. Conclusions: This study will provide data on expenditure for healthcare by households affected by advanced cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.

Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important?

Background: Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. Objective: We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). Design: Retrospective cohort study. Setting/Subjects: Patients with DC hospitalized at a single tertiary center and followed for one year. Measurements: We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). Results: Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. Conclusions: PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.

Association of socioeconomic disparities with underutilization of palliative care in patients with metastatic foregut cancer.

502 Background: Metastatic foregut cancers (MFC) are frequently associated with debilitating symptoms that have significant negative impact on patients’ quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects. However, PC remains heavily underutilized. The aim of our study was to characterize the rate of PC utilization in MFC and determine the impact of various clinicopathologic and socioeconomic factors associated with the receipt of PC. Methods: We conducted a retrospective review of 277,957 National Cancer Database patients diagnosed with MFC between 2004-2013. Chi-squared tests were used to analyze differences between groups. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. Results: PC utilization increased among all groups over time (12.3% 2004-2006 vs. 14.7% 2007-2010 vs. 16.4% 2011-2013 for all cancers). Female sex, Medicaid, median income &lt; $46,000/year, higher education level, higher Charlson/Deyo Score, and pancreatic or biliary cancers were associated with increased likelihood of PC interventions. Additionally, patients treated at an academic center or integrated network cancer program were more likely to receive PC than patients treated in the community setting. When receipt of PC was stratified by race, Hispanics were significantly less likely to have undergone palliative interventions compared to non-Hispanic Whites (OR 0.70, 95% CI 0.66-0.73). Patients with Medicare or private insurance were less likely to receive PC than uninsured patients (OR 0.92, 95% CI 0.87-0.97 and 0.81, 95% CI 0.77-0.89, respectively). Conclusions: Differences in palliative care receipt rates exist with regards to racial/ethnic and socioeconomic factors such as insurance status, median household income, and education level. Patients receiving care in the community setting were also less likely to receive palliative care than those treated at academic or integrated network cancer program centers. Further studies are needed to delineate why these disparities exist with regards to palliative care utilization.