Originally published as JCO Early Release 10.1200/JCO.2004.06.050 on November 1 2004

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Perspectives, Preferences, Care Practices, and Outcomes Among Older and Middle-Aged Patients With Late-Stage Cancer

From the Case Western Reserve University School of Medicine; MetroHealth Medical Center; Louis Stokes Cleveland Veterans Affairs Medical Center (VAMC) Geriatric Research Education and Clinical Center (GRECC); Center for Health Care Research and Policy, Cleveland, OH; Beth Israel Deaconess Medical Center, Boston, MA; Duke University School of Medicine, VAMC, Durham, NC.

Address reprint requests to Julia Hannum Rose, PhD, MA, Department of Medicine–Geriatrics, Case Western Reserve University, 2500 MetroHealth Dr, Cleveland, OH 44109; e-mail: julia.rose{at}case.edu

PURPOSE: To evaluate relationships among physician and cancer patient survival estimates, patients' perceived quality of life, care preferences, and outcomes, and how they vary across middle-aged and older patient groups.

PATIENTS AND METHODS: Subjects were from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) prospective cohort studied in five US teaching hospitals (from 1989 to 1994), and included 720 middle-aged (45 to 64 years) and 696 older ( 65 years) patients receiving care for advanced cancer. Perspectives were assessed in physician and patient/surrogate interviews; care practices and outcomes were determined from hospital records and the National Death Index. General linear models were used within age groups to obtain adjusted estimates.

RESULTS: Although most patients had treatment goals to relieve pain, treatment preferences and care practices were linked only in the older group. For older patients, preference for life-extending treatment was associated with more therapeutic interventions and more documented discussions; cardiopulmonary resuscitation (CPR) preference was linked to more therapeutic interventions and longer survival. For middle-aged patients, better perceived quality of life was associated with preferring CPR. In both groups, patients' higher survival estimates were associated with preferences for life-prolonging treatment and CPR; physicians' higher survival estimates were associated with patients' preferences for CPR, fewer documented treatment limitation discussions about care, and actual 6-month survival. More discussions were associated with readmissions and earlier death. More aggressive care was not related to outcomes.

CONCLUSION: Fewer older patients preferred CPR or life-prolonging treatments. Although older patients’ goals for aggressive treatment were related to care, this was not so for middle-aged patients. Aggressive care was not related to prolonged life in either group.

Supported by National Cancer Institute grant RO-1 CA72977-01 (J.H.R.). The SUPPORT Project was funded by the Robert Wood Johnson Foundation. The opinions in this manuscript do not necessarily represent the views of the Foundation.

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

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