Anna Collins1, Vijaya Sundararajan2, Jodie Burchell2, Jeremy Millar3, Sue-Anne McLachlan4, Meinir Krishnasamy5, Brian H Le6, Linda Mileshkin7, Peter Hudson8, Jennifer Philip9. 1. Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia. Electronic address: anna.collins@svha.org.au. 2. Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia. 3. Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia. 4. Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia. 5. Department of Nursing, University of Melbourne, Melbourne, Victoria, Australia. 6. Palliative Care Service, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia. 7. Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. 8. Centre for Palliative Care, St Vincent's Hospital Melbourne & University of Melbourne, Melbourne, Victoria, Australia; Vrije University, Brussel, Belgium. 9. Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.
Abstract
CONTEXT: Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level. OBJECTIVES: This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making. METHODS: Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser. RESULTS: About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120). CONCLUSION: Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice.
CONTEXT: Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level. OBJECTIVES: This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making. METHODS: Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser. RESULTS: About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120). CONCLUSION: Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice.
Authors: Joseph A Greer; Beverly Moy; Areej El-Jawahri; Vicki A Jackson; Mihir Kamdar; Juliet Jacobsen; Charlotta Lindvall; Jennifer A Shin; Simone Rinaldi; Heather A Carlson; Angela Sousa; Emily R Gallagher; Zhigang Li; Samantha Moran; Magaret Ruddy; Maya V Anand; Julia E Carp; Jennifer S Temel Journal: J Natl Compr Canc Netw Date: 2022-02 Impact factor: 11.908
Authors: Jennifer Philip; Anna Collins; Brian Le; Vijaya Sundararajan; Caroline Brand; Susan Hanson; Jon Emery; Peter Hudson; Linda Mileshkin; Soula Ganiatsas Journal: Pilot Feasibility Stud Date: 2019-03-14
Authors: Anna Collins; Vijaya Sundararajan; Brian Le; Linda Mileshkin; Susan Hanson; Jon Emery; Jennifer Philip Journal: Front Oncol Date: 2022-09-15 Impact factor: 5.738
Authors: Jennifer Philip; Roslyn Le Gautier; Anna Collins; Anna K Nowak; Brian Le; Gregory B Crawford; Nicole Rankin; Meinir Krishnasamy; Geoff Mitchell; Sue-Anne McLachlan; Maarten IJzerman; Robyn Hudson; Danny Rischin; Tanara Vieira Sousa; Vijaya Sundararajan Journal: BMC Health Serv Res Date: 2021-05-27 Impact factor: 2.655