At the end of life, doctors' actions and patients' wishes may be misaligned, according to a Rutgers Health study
For terminally ill cancer patients, the final days of life are immensely personal, having the choice to continue cancer treatments, or to stop treatments and prioritize a more comfortable passing.
What a patient wants, however, isn't always what they receive, according to a Rutgers Health study published in the journal Cancer.
"A patient's end of life is often not a reflection of what they want, but rather, who their oncologist happens to be," said Login S. George, a health services researcher at the Rutgers Institute for Health, Health Care Policy and Aging Research, and lead author of the national study. "The data doesn't indicate patient-centered treatment decisions, but rather, more habitual or default ways of treating patients," says George, who is also a member of the Cancer Prevention and Control Program at Rutgers Cancer Institute, the state's only National Cancer Institute-designated Comprehensive Cancer Center.
Clinical guidelines for many cancers recommend stopping chemotherapy in the final days of life as it can do more harm than benefit. But while such treatment discontinuation decisions should be based on clinical presentation and patients' preferences, oncologists could be making decisions based on their characteristic ways of proceeding in such contexts, George said.
To assess how oncologists treat terminally ill cancer patients, George and colleagues at Rutgers Health analyzed national data from the National Cancer Institute's Surveillance, Epidemiology and End Results program. By examining billing codes in Medicare hospital outpatient and carrier claims, they identified 17,609 patients from across the country who died of breast, lung, colorectal or prostate cancer from 2012 to 2017 and the 960 oncologists who treated them at 388 different practices and clinics.
With this data as a starting point, the researchers then used multilevel models to estimate oncologists' rates of prescribing chemotherapy and other systemic cancer therapies to their dying patients in the last two weeks of life. Oncologists were categorized as having "high" or "low" prescribing behavior depending on whether they prescribed to a higher or lower proportion of their patients, relative to their peers.
By accounting for variation coming from patient- and practice-level influences, the researchers were able to isolate the effects that the treating oncologist had on patients' end-of-life.
Results showed a patient receiving care from an oncologist with a high prescribing behavior had a striking 4.5-times higher odds of receiving cancer treatment in the final days of life, compared with a patient receiving care from an oncologist with a low prescribing behavior.
Additionally, individuals with breast cancer had higher odds of receiving late-stage treatment than those with lung cancer.
Other findings include:
- Patients with colon cancer and prostate cancer didn't differ from lung cancer patients.
- Black patients had lower odds of treatment in the last month of life compared with white patients.
- Unmarried (single, divorced or widowed) patients had lower odds of receiving treatment than married patients.
Because the data was anonymized, the researchers couldn't identify the prescribing oncologists by name or practice. But the results indicate that despite clinical prescribing guidelines, there remains significant variations in what terminally ill cancer patients receive at the end of their lives.
George said making this kind of information publicly available could help better align patients' treatment wishes with reality.
"When we go out to eat or go shopping, we don't just blindly pick a restaurant or randomly grab the first thing we see on the shelf. We look at the ratings and reviews to see what other people experienced as we make decisions," George said.
"Shouldn't patients with cancer have the same luxury?" he added. "As health care consumers, we have a right to know about the providers that we pick."
George said future research will examine the factors that fuel patients' and clinicians' decisions between more cancer treatments and hospice care.
The research was supported by the Rutgers Cancer Institute and the National Cancer Institute. Paul R. Duberstein from the Rutgers School of Public Health, Benjamin Bates from Rutgers Robert Wood Johnson Medical School and the Rutgers School of Public Health, Biren Saraiya and Sanjay Goel from the Rutgers Cancer Institute, and Ayse Akincigil, an associate professor at the School of Social Work, also co-authored the study.
