Discuss Hospice and Palliative Care With Cancer Patients

AUSTIN, TEX. — Some palliative chemotherapy regimens can cost up to $100,000 a year for end-of-life care. Yet oncologists and their patients often do not discuss less costly, alternative advanced-care options.

“This is going to come to the fore over the next year or two, as fewer and fewer people have insurance,” Dr. Thomas Smith said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. “We spend twice as much as any other country for the same cancer results.”

He noted that some insurance companies may soon be asking patients to pay more for third-line treatments because of their reduced possibility of benefit. If hospice is introduced early in treatment as an end-of-life option, moreover, patients tend to switch earlier and spend more time in hospice, thereby reducing patient and hospital costs. Currently, one-third of patients with cancer spend fewer than 7 days in hospice, he said.

A sea change may already be underway. Kaiser Permanente has put hospice and palliative care teams in all of its major markets, and many insurers (such as UnitedHealthcare) are expected to roll out their plans for concurrent oncology and palliative care later this year, said Dr. Smith, professor of palliative care research at Virginia Commonwealth University in Richmond.

Part of the problem is that neither oncologists nor patients want to talk about death. A recent study showed that oncologists discussed prognosis 39% of the time and impending death only 37% of the time (JAMA 2008;300:1665–73). Of 111 inpatients with cancer, only 23 said they wished to discuss their advanced-care preferences with their oncologists, and 64 said they would prefer to do so with an admitting doctor (J. Palliat. Med. 2000;3:27–35).

Reimbursement is also a thorny issue. The Medicare reimbursement for hospice and palliative care hasn't kept pace with inflation or current oncology practice trends, even though patients with cancer account for about 40% of Medicare drug costs, Dr. Smith said. Oncologists are reimbursed far more for administering chemotherapeutic agents than for having discussions about prognosis and palliative care options.

It's also hard to find good “bad” news, Dr. Smith said. He noted that treatment options for recurrent pancreatic cancer on the National Cancer Institute's Web site (www.cancer.gov

“How about putting on there [that] in fact 95% of people are going to be dead within a year … and suggest hospice and palliative care?” he asked. “I've been beating on the NCI for 15 years on this, and will probably die before it happens.”

For those who say patients can't handle the truth, Dr. Smith said it is nearly impossible to take away hope. Most cancer patients are overly optimistic about their prognosis and are willing to take a phase I drug, even if it has a 10% chance of killing them.

New data suggest that one of the biggest fears of the terminally ill is abandonment by their physician or nurse when disease-modifying therapy is no longer an option (Arch. Intern. Med. 2009;169:474–9).

Written treatment plans offer patients truthful information about prognosis and treatment effectiveness, Dr. Smith said. He has been using them in his practice for years, and noted that the American Society of Clinical Oncology now makes these plans available online (www.asco.org

During the same presentation, Dr. Sarah E. Harrington offered suggestions for what oncologists should say about illness and patient options. They include being realistic about the goals of therapy; defining cure, remission, response, and what is likely to happen; and being negative, if appropriate.

“Language is important. Patients can easily mistake a 20% chance of response for a 20% chance of cure,” said Dr. Harrington, also at Virginia Commonwealth.

The subject of hospice should be brought up early as part of routine oncologic care, rather than delayed until death is imminent. Oncologists should be especially realistic about nth-line chemotherapy. If no proof of benefit is available, don't offer it, she said. To avoid feelings of abandonment, oncologists should tell their patients they will not abandon them if they enroll in hospice.

Dr. Harrington and Dr. Smith referred the audience to a recent article in which they discussed questions patients should consider when asking about palliative chemotherapy, and what oncologists should or should not do or say about chemotherapy for advanced cancer (JAMA 2008;299:2667–78).

They reported no financial disclosures.