Expert Perspective

“As a doctor who specializes in caring for vulnerable, mostly older adults with cancer, my biggest wish for every one of my patients is that they have choice and comfort throughout care, including during the care they receive at the end of their lives,” said 2019 Supportive Care in Oncology Symposium News Planning Team Chair William Dale, MD, PhD. “This study identifies a specific point in the care of patients with pancreatic cancer where racial and ethnic inequities exist. It is the first step in helping us better understand and improve earlier access to hospice care for all patients with pancreatic cancer so they can have the best end of life possible.”

This summary includes updated data not in the abstract.

ALEXANDRIA, Va. – An analysis of Medicare claims data found that African American and Hispanic patients who underwent surgical removal of the pancreas for pancreatic cancer were less likely than white patients to use hospice services at the end of life, though all groups were just as likely to use hospice late, meaning initiation within 3 days of death. These findings will be presented at the upcoming 2019 Supportive Care in Oncology Symposium, in San Francisco, CA.

“Though barriers to hospice care exist among racial and ethnic minorities, when accessed hospice services has the potential to facilitate an end of life patients envision,” said lead study author Anghela Z. Paredes, MD, MS, a surgical resident at The Ohio State University in Columbus, OH, and recipient of a 2019 Conquer Cancer of ASCO Resident Travel Award for Underrepresented Populations. “For patients with life-limiting illnesses, planning or integrating hospice earlier may provide them an opportunity to think about goals and desires for their remaining days and helps them design a care plan that they are more comfortable with.”

Despite advances in pancreatic cancer research, the disease remains difficult to treat. The 5-year survival rate for people with pancreatic cancer is 9%. This year, around 56,770 adults in the United States will be diagnosed with pancreatic cancer, and incidence rates are 25% higher in African American people than in white people.[1]

About the Study, Key Findings

Using Medicare claims files, researchers identified 14,495 patients who had undergone surgical removal of the pancreas (pancreatectomy) for pancreatic cancer. All patients had equal insurance coverage – they were enrolled in both Medicare Parts A and B at the time of surgery and had no additional coverage through other insurers.

The median age of patients was 73 years, and 980 (6.8%) were African American or Hispanic, whereas a majority (13,515, 93.2%) were white. The records included 7,581 males (52%) and 6916 females (48%). According to the authors, this is the largest analysis to date of racial/ethnic trends of hospice use and timing among patients with pancreatic cancer who have had a pancreatectomy.

Researchers then analyzed the records of the 6,859 patients (47%) who were deceased by the end of the follow-up period (December 31, 2017). The researchers found that despite similarities in sex, age, comorbidities, and insurance status, African American and Hispanic patients were 22% less likely to use hospice care than white patients. Only 67% of African American and Hispanic patients (301) had used hospice care as compared with 73% of white patients (4,677).

Of the patients in this group, only 72.6% (4,978) used hospice services at time of death, and minority and white patients were just as likely to initiate hospice late (i.e., initiation within 3 days of death). Ideal hospice use (i.e., the number of days before death hospice should be initiated) is not well defined according to Dr. Paredes, however, she notes that previous research has shown that late hospice use is associated with receipt of life-sustaining measures and higher Medicare expenditures[2].

“Hospice and palliative care are not just the responsibility of medical oncologists,” said Dr. Paredes. “All cancer care providers need to incorporate hospice into the treatment strategy early on. We need to be comfortable discussing our patients’ end-of-life goals and exploring what services could help them ensure their best quality of life at the end-of-life.”

Next Steps

Dr. Paredes noted that the study does not explain why patients may have delayed, avoided, or not used hospice care, nor does it provide information about the quality of care each patient received, level of family and social support, or distance of the hospice facility from the patient’s home, among other factors. Additionally, the study focused on patients with equal insurance, and may not reflect trends in use and timing of hospice in uninsured patients.

For next steps, researchers plan to study the racial/ethnic disparity found in this analysis more deeply and work to better understand the barriers to hospice care that people with pancreatic cancer in racial/ethnic minority populations experience, as well as the barriers to earlier initiation of hospice.

This year’s Supportive Care in Oncology Symposium will include approximately 150 abstracts focusing on efforts to improve supportive care for patients with cancer. On-site facilities for reporters will include a working newsroom and access to leading experts in supportive care.

Information for Media

Doctor-approved patient information for your readers from Cancer.Net:

• Hospice Care
• Health Disparities and Cancer
• Health Disparities Resources

2019 Supportive Care in Oncology Symposium News Planning Team

• Chair: William Dale, MD, PhD (ASCO)

• Joseph Rotella, MD, MBA, HMDC, FAAHPM (AAHPM)

• Monica S. Krishnan, MD (ASTRO)

View the disclosures for the News Planning Team.

ATTRIBUTION TO THE 2019 SUPPORTIVE CARE IN ONCOLOGY SYMPOSIUM IS REQUESTED IN ALL NEWS COVERAGE.
 

Abstract 41: Racial/ethnic disparities in hospice utilization among Medicare beneficiaries dying from pancreatic cancer

Authors: Anghela Paredes, Madison Hyer, Elizabeth Palmer, Maryam B. Lustberg, Timothy M. Pawlik; Ohio State University Wexner Medical Center, Columbus, OH; The Ohio State University Wexner Medical Center, Columbus, OH; Ohio State University Comprehensive Cancer Center, Division of Medical Oncology, Columbus, OH; Johns Hopkins University School of Medicine, Baltimore, MD

Background: While racial/ethnic treatment disparities among patients with pancreatic cancer have been documented, variation in other aspects of care including hospice utilization have not. As such, we sought to define the incidence, as well as characterize the timing, of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. Methods: The Medicare Standard Analytic Files were used to identify white and racial/ethnic minorities (African Americans and Hispanics) who underwent pancreatectomy for pancreatic cancer. Trends and timing related to overall hospice utilization among racial/ethnic minority and white patients were analyzed. Results: Among the 6,530 individuals (median age: 73, IQR 69-78; 51.5% female; 6.6% % racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 64.6% (n = 4221) had died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 3149, 74.6%) had used hospice leading up to the time of death. Among individuals who died, age and comorbidity burden were similar among racial/ethnic minority and white patients; racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities: n = 188, 68.9%, whites: n = 2,961, 75.0%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 27% less likely than whites to initiate hospice services prior to death (OR 0.73, 95%CI 0.56-0.95, p = 0.021). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e. within 3 days of death) versus white patients (OR 0.75, 95% CI 0.49-1.14, p = 0.18). Conclusions: While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, ethnic/racial minority were less likely to use hospice services than whites. Further research should seek to better understand possible barriers to hospice initiation among racial/ethnic minority patients with cancer.

Disclosures: Maryam B. Lustberg, MD: Consulting or Advisory Role with Tempus and PledPharma, Other Relationship with Cynosure/Hologic

Research Funding Source: No funding received

Grant Funding: Resident Travel Award for Underrepresented Populations (RTA), 2019