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Cancer Patients Get Aggressive Care at End

Hospice becoming more common, but new drugs hold powerful appeal

WEDNESDAY, Jan. 14, 2004 (HealthDayNews) -- A growing number of people with deadly cancers have aggressive treatments in the months, weeks and even days before their death, a new study finds.

The study suggests the value of comfort care for the terminally ill often gets obscured by the arrival of novel -- if only modestly effective -- medications.

The work appears in the Jan. 15 issue of the Journal of Clinical Oncology.

Hospice care, which specializes in easing pain and suffering in a person's last days, became more widely used during the years studied. Yet a wave of new cancer drugs in the mid-1990s gave patients on the edge of death a few more months. That promise was enough to prompt doctors to prescribe -- and patients to accept -- the new therapies even though they also promised prolonged suffering.

"When more chemotherapy becomes available we're using it," says research leader Dr. Craig Earle, a cancer specialist at Harvard Medical School and the Dana-Farber Cancer Center in Boston. "As hospice becomes more available, it can also counterbalance that effect."

Roughly 15 percent of Americans die at home with hospice care, according to a study in the Jan. 7 issue of the Journal of the American Medical Association; the rest die in institutional settings such as hospitals or nursing homes. Family members of people who received hospice treatment before they died are far more likely to express satisfaction with that care than the relatives of patients who died in hospitals, the study found.

While the latest study's last year was 1996, Earle believes the trends it describes continue. The researchers have a follow-up study planned that will include data through 2000.

Earle's group looked at medical records of 28,777 elderly cancer patients, most with lung tumors, enrolled in the government's Medicare insurance program between 1993 and 1996. Using the administration of cancer drugs as a measure of aggressive care, the researchers saw that rates of chemotherapy rose slightly throughout the study, from 27.9 percent of patients in 1993 to 29.5 percent in 1996.

The researchers also found the window between the start of the last new cancer drug and death shrunk from 140 days to 127 days. So did the time between the last dose of any chemotherapy and death, from 71 days to 65 days.

The medications "do improve survival modestly, in the range of a few months," says Earle, "which is why we looked not so much as whether they were treated or how many drugs they received but how late" in the course of a person's disease the treatment began.

Emergency room admissions and stays in intensive care wards, other measures of aggressive care, also climbed during the study period. However, these likely reflect the frequent presence of other serious illnesses in cancer patients, Earle says. "Whether that means we're increasingly treating patients with [many ailments at once] or not, and whether that's appropriate is another question," he says.

The proportion of patients who died in the hospital fell slightly, while the share of those who entered hospice care jumped from 28 percent to 38 percent by 1996. Still, more people who went into hospice over time did so in their last three days of life -- 14 percent in 1993 versus 17 percent in 1996 -- suggesting the option was being delayed.

Dr. Albert W. Wu, an end-of-life care expert at Johns Hopkins University's Bloomberg School of Public Health in Baltimore, says studies like the latest one paint a "consistent" picture of how dying Americans are treated.

"How sick you are or how remote your chances of survival are does not affect aggressiveness of treatment until the bitter end, which could be just within days," Wu says. At that point, the shift to comfort care "can be interpreted more as a last rite than as a real change in approach. It basically is not rational to treat absolutely full bore until the last hour of life," he adds.

More information

To learn more about hospice care, visit the Hospice Foundation of America. For more on cancer, visit the American Cancer Society.

SOURCES: Craig Earle, M.D., assistant professor, Harvard Medical School, Boston; Albert W. Wu, M.D., M.P.H., associate professor of health policy and management, Johns Hopkins University Bloomberg School of Public Health, Baltimore; Jan. 15, 2004, Journal of Clinical Oncology
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