Aggressiveness of care at the end of life for cancer patients in Portugal

7 out of 10 cancer patients who die in a public hospital in mainland Portugal are exposed to overly aggressive treatments that could compromise the quality of life at its end. Clinicians should consider cancer type, disease stage, comorbidities, age, and the influence of hospital oncology culture, to help patients with cancer to avoid aggressiveness of cancer care at the end of life.

Authors and Affiliations:

Diogo Martins ­Branco^1,2, Silvia Lopes^3,4, Rita Canario^1,5, João Freire², Madalena Feio⁶, José Ferraz-Gonçalves⁷, Gabriela Sousa⁵, Nuno Lunet^8,9, Barbara Gomes^1,10

¹ Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London; Bessemer Road, London SE5 9PJ, United Kingdom;

² Medical Oncology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil; Rua Professor Lima Basto, 1099-023 Lisbon, Portugal;

³ NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa; Avenida Padre Cruz, 1600-560 Lisbon, Portugal;

⁴ Comprehensive Health Research Centre; Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal;

⁵ Medical Oncology Department, Instituto Português de Oncologia de Coimbra Francisco Gentil, Av. Bissaya Barreto 98, 3000-075 Coimbra, Portugal;

⁶ Hospital Palliative Care Support Team, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Professor Lima Basto, 1099-023 Lisbon, Portugal;

⁷ Palliative Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Rua Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal;

⁸ Department of Public Health and Forensic Sciences and Medical Education, University of Porto Medical School, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal;

⁹ EPIUnit, Institute of Public Health, University of Porto, Rua das Taipas 135, 4050-600 Porto, Portugal;

¹⁰ Faculty of Medicine, University of Coimbra, Rua Larga, 3004-504 Coimbra, Portugal.

Abstract:

Factors associated with the aggressiveness of care at the end of life for patients with cancer dying in hospital: a nationwide retrospective cohort study in mainland Portugal

Introduction: There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL), defined as overly aggressive treatments that compromise the quality of life at its end. Recognising the most affected patients is a cornerstone to improve oncology care. Our aim is to identify factors associated with ACCEoL for patients with cancer dying in hospitals.

Methods: All adult patients with cancer who died in public hospitals in mainland Portugal (January 2010 to December 2015), identified from the hospital morbidity database. This database provided individual clinical and demographic data. We obtained hospital and region-level variables from a survey and National Statistics. The primary outcome is a composite ACCEoL measure of 16 indicators. We used multilevel random effects logistic regression modelling (p<0·05).

Results: We included 92 155 patients: median age 73 years; 62% male; 53% with metastatic disease. ACCEoL prevalence was 71% (95% CI 70% to 71%). The most prevalent indicators were >14 days in the hospital (43%, 42–43) and surgery (28%, 28–28) in the last 30 days.

Older age (p<0·001), breast cancer (OR 0·83; 95% CI 0·76 to 0·91), and metastatic disease (0·54; 95% CI 0·50 to 0·58) were negatively associated with ACCEoL. In contrast, higher Deyo-Charlson Comorbidity Index (p<0·001), gastrointestinal and haematological malignancies (p<0·001), and death at cancer centre (1·31; 95% CI 1·01 to 1·72) or hospital with medical oncology department (1·29; 95% CI 1·02 to 1·63) were positively associated with ACCEoL. There was no association between hospital palliative care services at the hospital of death and ACCEoL.

Conclusion: Clinical factors related to a better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and gastrointestinal malignancies might represent groups with complex needs, and haematological patients may be at increased risk because of unpredictable prognosis. Improvement of hospital palliative care services could help reduce ACCEoL, particularly in cancer centres and hospitals with medical oncology department, as those services are usually under-resourced, thus reaching few.

Journal: ESMO Open

Link: https://www.esmoopen.com/article/S2059-7029(20)32745-9/fulltext