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Trends in the Aggressiveness of Cancer Care Near the End of Life

From the Divisions of Population Sciences and Psychosocial Oncology and Palliative Care, Department of Medical Oncology, Dana-Farber Cancer Institute; Department of Health Care Policy, Harvard Medical School; and Division of General Medicine and Department of Psychiatry, Brigham & Women’s Hospital, Boston, MA

Address reprint requests to Craig C. Earle, MD, MSc, Center for Outcomes and Policy Research, Dana-Farber Cancer Center, 44 Binney St, 454-STE 21-24, Boston, MA 02115; e-mail: craig_earle{at}dfci.harvard.edu.

PURPOSE: To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources.

PATIENTS AND METHODS: We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program.

RESULTS: Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P = .02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P < .001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P < .001), hospitalization (7.8% v 9.1%; P = .008), or were admitted to an intensive care unit (7.1% v 9.4%; P = .009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P < .001) and more used hospice services (28.3% v 38.8%; P < .001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P = .004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis.

CONCLUSION: The treatment of cancer patients near death is becoming increasingly aggressive over time.

Supported by a grant from the National Cancer Institute (CA 91753-02).

Presented at the 39th Annual Meeting of the American Society of Clinical Oncology, May 31-June 3, 2003, Chicago, IL.

Authors’ disclosures of potential conflicts of interest are found at the end of this article.

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