Even at the end of life, nonwhite patients with ovarian cancer are more likely to receive suboptimal care.
That’s the finding of investigators who looked at Medicare-enrolled patients with end-stage ovarian cancer in Texas. They found that compared with white patients, nonwhites were less likely to be enrolled in or die in hospice, more likely to be admitted to an intensive care unit, more likely to have an emergency department visit, and more likely to be subjected to some kind of putatively life-extending intervention.
“More investigation is needed to determine not only how to best reduce the overall number of patients with ovarian cancer who receive aggressive and invasive care but also how to lessen the disparity of who receives more aggressive and invasive care. With regard to end-of-life care for patients with ovarian cancer, less may be more,” wrote Jolyn S. Taylor, MD, MPH, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues (J Clin Oncol. 2017 April 7 doi: 10.1200/JCO.2016.70.2894).
Quality-of-care recommendations from the American Society of Clinical Oncology Quality Oncology Practice Initiative, Physician Consortium for Performance Improvement, and National Quality Forum call on clinicians to recognize that excessive or aggressive end-of-life interventions can have a negative effect on the quality of life for patients with limited life expectancy, the authors noted.
“Although changes have occurred over the last decade leading to increased hospice use by patients with ovarian cancer before death, many patients still receive intensive and invasive care in the last month of life. Similar to other disease sites, patients of minority race and ethnicity and lower socioeconomic status who have ovarian cancer have been reported to have less hospice use and more intensive end-of-life care,” the researchers wrote.
To see whether these disparities still existed, the investigators examined Texas Cancer Registry–Medicare data on patients who died from ovarian cancer from 2000 to 2012 who had least 13 months of continuous Medicare coverage before their deaths. They looked for specific measures of end-of-life care quality, including chemotherapy use within 2 weeks of death, ICU admission in the last month of life, and emergency department visits, hospital admissions, or invasive or life-extending procedures, all during the last 30 days of a patient’s life.
Of the 3,666 patients studied, 2,819 (77%) were white, 553 (15%) were Hispanic, 256 (7%) were black, and 38 (1%) were classified as “other.”
In multivariate regression models adjusted for year of death, age at death, time from diagnosis to death, Charlson comorbidity index score, disease stage at diagnosis, educational and poverty level by census tract, and geography (rural versus urban), the researchers found that both black and Hispanic patients were significantly less likely than were white patients to enroll in and die in hospice, with odds ratios (OR) of 0.66 for black patients (P = .004), and 0.76 for Hispanics (P = .01).
Black but not Hispanic patients were more likely to have had more than one emergency department visit within 30 days of death (OR 2.20, P less than .001), or a life-extending procedure (OR 2.13, P less than .001). Hispanic but not black patients were more likely to have been admitted to an ICU within a month of death (OR 1.37, P = .02).
The study was supported by grants from the Cancer Prevention & Research Institute of Texas, National Institutes of Health, National Cancer Institute, and Duncan Family Institute.