Prevalence, Correlates, & Outcomes of Chemotherapy for Patients

Prevalence, Correlates, & Outcomes of Chemotherapy for Patients

Prevalence, Correlates, & Outcomes of Chemotherapy for Patients with End-Stage Gastrointestinal Cancers Holly G. Prigerson, PhD Renee C. Maciejewski, BS Manish A. Shah, MD Yuhua Bao, PhD Paul K. Maciejewski, PhD Center for Research on End-of-Life Care Weill Cornell Medicine Learning Objectives After this presentation, participants should know the: prevalence patient profile outcomes associated with chemotherapy use for GI cancer patients who are nearing death Presented by: Holly G. Prigerson, Ph.D Presentation Outline This talk will present data on the: a. frequency b. correlates c. harms & benefits of chemotherapy use in patients in their final months of life Presented by: Holly G. Prigerson, Ph.D. Frequency of chemotherapy use in GI cancer patients near death Administration codes from SEER-Medicare data reveal that: Stage IV pancreatic cancer patients diagnosed 2006 2011 who died within a year of their diagnosis (total N=7998): 35% chemotherapy Stage IV pancreatic cancer patients diagnosed in 2011 and then died in 2012 (total N=1270): 37% chemotherapy Presented by: Holly G. Prigerson, PhD Frequency of chemotherapy use in GI cancer patients near death

From Coping with Cancer NCI R01 data: Sites: Yale Cancer Center, Dana-Farber/BWH, MGH, University of Texas Southwestern (Parkland, Simmons), Pomona Valley Hospital, New Hampshire Oncology Hematology, Weill Cornell/Meyer, University of New Mexico, Massey, Memorial Sloan-Kettering Cancer Centers Patients: GI cancer patients distant mets and refractory to at least 1 line of chemotherapy a median of 4 months from death CwC I (2002-2008): 50% patients using chemotherapy at baseline assessment Presented by: Holly G. Prigerson, Ph.D From Coping with Cancer NCI R01 CwC II data (2010-2015): The question Are you currently receiving chemotherapy? The answer: pre-restaging scan = 90% receiving chemotherapy post-restaging scan = 81% receiving chemotherapy In the medical chart abstraction following restaging scan: 86% current chemotherapy use Across pre, post, and the med chart: 94%! receive chemotherapy Presented by: Holly G. Prigerson, Ph.D Participants characteristics by chemotherapy at study enrollment Before propensity weighted After propensity weighted All participant s (n=386) Age (yrs) Male Married Insured Mean (SD) years of education Race/ ethnicity: White Black Hispanic Asian Religion:

Catholic Protestant Jewish Muslim No religion Pentecostal Baptist 58.4 (12.5) 215 (56) 236 (61) 238 (62) adjustment Chemotherapy Yes (n=216) No (n=170) adjustment Chemotherapy P- value 56.4 61.0 (12.5) <0.001 (12.3) 119 (55) 96 (56) 0.8 142 (66) 94 (55) 0.04 145 (67) 93 (55) 0.02 12.6 (4.0) 13.3 (3.9) 11.6 (4.0) 251 (65) 70 (18) 57 (15) 5 (1) 147 (68) 36 (17) 26 (12)

5 (2) 141 (36) 68 (18) 18 (5) 5 (1) 17 (4) 9 (2) 58 (15) 76 (35) 42 (19) 14 (6) 3 (1) 8 (4) 6 (3) 29 (13) 104 (61) 34 (20) 31 (18) 0 (0) 65 26 4 2 9 3 29 (38) (15) (2) (1) (5) (2) (17) <0.001 0.1 0.5 Yes (n=216) 57.9 (11.9) (55.8)

(58.0) (55.9) No (n=170) 57.9 (12.2) (55.8) (58.0) (55.8) 11.9 (4.1) 11.9 (4.2) (58.7) (22.1) (18.4) (0.7) (58.7) (22.1) (18.4) (0.0) (34.6) (16.0) (3.4) (0.7) (6.1) (3.7) (17.0) (34.6) (16.0) (3.4) (0.7) (5.0) (1.7) (19.5) P-value >0.9 >0.9 0.8 0.8

>0.9 0.7 >0.9 Those getting chemo are: younger married insured better educated Participants characteristics by chemotherapy at study enrollment All participant s (n=386) Mean (SD) performanc e status: Karnofsky 64.8 (16.2) score ECOG score 1.7 (0.9) Charlson Comorbidity 8.3 (2.7) Index Mean (SD) McGill Quality of Life: Physical 5.7 (2.6) functioning Symptoms 5.4 (2.1) Psychologica 7.2 (2.5) l: Depressed 7.4 (2.9)

Worried 6.9 (3.2) Sad 7.3 (3.0) Terrified 7.2 (3.1) Support 8.6 (1.6) Sum score of quality of 6.8 (1.5) life Before propensity weighted adjustment Chemotherapy P value Yes (n=216) No (n=170) 69.0 (14.8) 59.5 (16.4) <0.001 1.5 (0.9) 2.0 (0.9) <0.001 7.9 (2.3) 8.8 (3.0) 0.002 6.1 (2.4) 5.3 (2.9) 0.004 5.8 (2.0)

4.9 (2.1) <0.001 7.6 (2.4) 6.7 (2.6) 0.002 7.7 7.2 7.9 7.4 8.6 7.0 6.4 6.4 7.0 8.7 (2.7) (3.0) (2.7) (2.8) (1.7) 7.0 (1.4) (3.2) (3.3) (3.2) (3.4) (1.6) 6.6 (1.6) 0.03 0.01 <0.001 0.2 0.9 0.002 Those getting chemo: better performance status

better QoL at baseline (when on chemo) Participants characteristics by chemotherapy at study enrollment All participants (n=386) Institution: Yale Cancer Center Veterans Affairs CCC Parkland and Simmons Cancer Center MSKCC Dana-Farber and Massachusetts General New Hampshire Oncology Hematology Cancer: Lung Pancreatic Colorectal Other gastrointestinal Breast Other Before propensity weighted adjustment Chemotherapy Yes (n=216) No (n=170) 75 (19) 58 (27) 17 (10) 19 (5)

8 (4) 11 (6) 188 (49) 106 (49) 82 (48) 28 (7) 26 (12) 2 (1) 7 (2) 3 (1) 4 (2) 67 (17) 14 (6) 53 (31) 85 (22) 36 (9) 57 (15) 43 (20) 27 (13) 38 (18) 42 (25) 9 (5) 19 (11) 57 (15) 27 (13) 30 (18) 42 (11) 110 (29)

27 (13) 54 (25) 15 (9) 56 (33) P value <0.001 0.02 Those getting chemo are: > academic (MSKCC) < community (NHOH) cancer centers > GI cancers (75% pancreatic) Participants characteristics by chemotherapy at study enrollment All participants (n=386) Before propensity weighted adjustment Chemotherapy Yes (n=216) No (n=170) P value Treatment preferences and planning: Wants prognostic information 269 (69) 152 (70) 117 (69)

0.8 Life extending care over comfort care 129 (31) 85 (37) 44 (24) 0.01 Chemotherapy to extend life by 1 week 288 (77) 186 (89) 102 (62) <0.001 Wants to avoid dying in ICU 161 (39) 76 (33) 85 (47) 0.1 Those getting chemo: want lifeprolonging>comfort care want chemo even if prolongs life just a week Presented by: Holly G. Prigerson, Ph.D Participants characteristics by chemotherapy at study enrollment All participants

(n=386) Completed living will or DPA Completed DNR order Terminal illness acknowledgme nt Patientphysician communication : Therapeutic alliance with physician Discussed end of life wishes with physician Coping style: Active Emotional Behavioral disengagement Mean (SD) positive religious coping Before propensity weighted adjustment Chemotherapy Yes (n=216) No (n=170) P value 214 (55) 111 (51) 103 (61) 0.1 161 (42) 77 (36)

84 (49) <0.05 159 (40) 76 (35) 83 (47) 0.04 244 (64) 131 (62) 113 (67) 0.3 162 (42) 80 (37) 82 (48) 0.03 177 (46) 190 (49) 105 (49) 106 (49) 72 (42) 84 (49) 0.3 >0.9 82 (21) 31 (14) 51 (30) <0.001

11.2 (6.4) 11.3 (6.3) 11.0 (6.5) 0.6 Those getting chemo: are less likely to complete a DNR order & acknowledge theyre terminally ill are less likely to discuss EOL care preferences more engaged (less withdrawn) Presented by: Holly G. Prigerson, Ph.D Outcomes of chemotherapy use Associations between chemotherapy at study enrollment and intensity of end of life care. Propensity weighted adjusted analysis Medical care in last week* Chemotherapy at enrollment Risk difference (95% CI) P value Yes No CPR, ventilation, or both 24 (12) 4 (2) 10.5 (5.0 to15.5)

<0.001 Admission to intensive care unit 26 (13) 15 (8) 5.6 (0.5 to 11.7) 0.07 Chemotherapy 12 (6) 10 (5) 1.1 (3.6 to 5.7) 0.7 Feeding tube for enteral nutrition 22 (12) 9 (5) 7.1 (1.7 to 12.5) 0.01 Hospice 1 week 96 (52) 70 (38) 13.6 (3.6 to 23.6) 0.008 Outcomes of chemotherapy use Unadjusted analysis

Variable* Chemotherapy at enrollment Yes (n=216) No (n=170) Intensive care unit 24 (11) 4 (2) Hospital 54 (25) Propensity weighted adjusted analysis Risk difference (95% CI) Chemotherapy at enrollment Risk difference (95% CI) P value Yes No 8.8 (4.0 to 13.6) 19 (10) 7 (4) 6.1 (1.1 to 11.1)

0.02 26 (15) 9.8 (1.9 to 17.8) 38 (21) 32 (17) 3.6 (4.1 to 11.3) 0.4 102 (47) 112 (66) 18.4 (8.7 to 28.2) 100 (52) 122 (63) 10.8 (1.0 to 20.6) 0.03 28 (13) 19 (11) 1.8 (4.7 to 8.4) 26 (13) 22 (12) 2.0 (4.6 to 8.7) 0.6 7 (3)

9 (5) 2.0 (6.2 to 2.1) 7 (4) 9 (5) 1.0 (5.0 to 3.1) 0.6 140 (65) 135 (80) 12.4 (3.6 to 21.2) 131 (68) 154 (80) 9.4 (0.8 to 18.1) 0.03 Place of death: Home Inpatient hospice Nursing home Title of graphic Death in preferred place Presented by: Holly G. Prigerson, Ph.D Prigerson et al. JAMA Oncol. 2015

Patients Higher Quality of Life Near Death Stratified by Baseline Performance Status and Chemotherapy Use ECOG indicates Eastern Cooperative Oncology Group. Performance status was measured by ECOG score as follows: 1. symptomatic, ambulatory 2. symptomatic, in bed less than 50% of the time 3. symptomatic, in bed more than 50% of the time 69% 44% Conclusions Prevalence of chemotherapy in GI cancer patients within months of death is: frequent (~ 50%) nearly universal at academic medical centers becoming more common Presented by: Holly G. Prigerson, Ph.D Conclusions GI cancer patients with progressive metastatic disease receiving chemo are more likely to be: younger married better educated > academic cancer clinics; < community cancer clinics Presented by: Holly G. Prigerson, Ph.D Conclusions GI cancer patients with progressive metastatic disease who are receiving chemo are more likely than those who do not to: have better baseline performance status, QoL want life-prolonging care, including chemo even if only enhancing survival by a week lower rates of DNR order completion, terminal illness acknowledgment, & EoL discussions Presented by: Holly G. Prigerson, Ph.D

Conclusions GI cancer patients with progressive metastatic disease who get chemo are at risk in their last week of: CPR feeding tube ICU stay and death hospice stays of only a few days not dying at home or in preferred place of death Presented by: Holly G. Prigerson, Ph.D Conclusions GI cancer patients near death who get chemo are likely to have: good performance status and, therefore, have the most to lose as they are: are more likely to have poor quality of death Presented by: Holly G. Prigerson, Ph.D We appreciate this opportunity to present at ASCO 2016 GI Cancers Symposium! Thank You! Presented by: Holly G. Prigerson, Ph.D Chemotherapy Use, Performance Status, & Quality of Life at the End of Life Prigerson et al. JAMA Oncology 2015

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