Early Palliative Care Linked to Better End-of-Life Outcomes in Ovarian Cancer

Initiating palliative care (PC) more than 3 months before death was associated with improved quality of care and reduced care intensity at the end of life (EOL) for decedents with ovarian cancer, according to a study published in JAMA Network Open.¹

Alongside oncologic treatment, the American Society of Clinical Oncology recommends all patients with advanced cancer receive early, dedicated PC within 8 weeks of diagnosis.² PC benefits include prolonged survival, enhanced quality of EOL care, and improved patient and caregiver quality of life (QOL).¹ Early referral to specialist PC is also linked to less aggressive EOL care.

Despite experiencing a greater symptom burden earlier in their disease course than those with other solid tumors, the optimal timing for early PC initiation in patients with gynecologic cancers remains unclear. Previous studies suggest that increased PC access has not reduced EOL care intensity in this population, and late PC consultations have shown limited impact on EOL quality indicators. To address this, the researchers investigated the relationship between PC timing and EOL care aggression among decedents with ovarian cancer.

Initiating palliative care more than 3 months before death improves end-of-life outcomes for patients with ovarian cancer. | Image Credit: Chinnapong - stock.adobe.com

They used linked administrative Institute for Clinical Evaluative Sciences (ICES) data to identify patients in Ontario, Canada, who died of ovarian cancer between 2006 and 2018, excluding those younger than 18 years or those who had invalid health card numbers. Patient health care numbers were then linked to various administrative databases to analyze diagnoses, procedures, chemotherapy use, and PC services.

The researchers classified PC services as specialist or nonspecialist and institutional or community based, identifying them using validated administrative codes. Also, specialist PC initiation was defined as the first inpatient or outpatient consult, and late PC was defined as services provided within 3 months of death.

Using these data, the researchers assessed EOL care quality indicators, with EOL defined as the final 30 days of life. Indicators were grouped into 2 categories: aggressive (multiple emergency department [ED] visits, hospitalizations, or intensive care unit [ICU] admissions) or supportive (physician house calls or palliative home care) care. They used multivariable logistic regression to examine the link between PC timing and EOL care, adjusting for comorbidities like cancer stage at diagnosis and age at death.

The study population consisted of 8297 decedents with ovarian cancer. The mean (SD) length of oncologic survival was 2.8 (3.9) years, with the mean age at death being 69.6 (13.1) years. Of 3958 (47.7%) patients with available cancer stage data, 2366 and 1129 presented with stage III and IV disease, respectively.

Also, 7970 (96.1%) patients initiated PC a median (IQR) of 238 (55-633) days before death. PC was initiated late for 2667 patients (32.1%), with 1304 (15.7%) doing so in the final 30 days of life and 1363 (16.4%) between 1 and 3 months before death.

Compared with those with earlier PC, decedents who initiated PC late had higher rates of the following individual aggressive EOL care quality indicators: ED visits in the final 14 days of life (43.1% vs 25.2%-30.7%), new hospitalization in the final 30 days of life (68.3% vs 42.0%-50.2%), new ICU admission in the final 30 days of life (8.9% vs 2.8%-3.7%), late chemotherapy (7.8% vs 4.2%-4.6%), and death in the hospital (56.3% vs 36.7%-38.3%).

Overall, 29.7% of those with late PC experienced aggressive EOL care vs 15.8% to 18.2% of those with earlier PC. More specifically, decedents with PC from 3 to 6 months before death were significantly less likely to receive aggressive EOL care (OR, 0.47; 95% CI, 0.37-0.60), be admitted to the ICU in their final 30 days (OR, 0.46; 95% CI, 0.27-0.76), or die in the hospital (OR, 0.54; 95% CI, 0.45-0.65) than those with late PC.

Only 4298 patients (51.8%) received a specialist PC consultation. Compared with those who received late specialist PC, patients who received specialist PC between 3 to 6 months before death were less likely to receive supportive EOL care (OR, 1.52; 95% CI, 1.23-1.88) and less likely to die in the hospital (OR, 0.66; 95% CI, 0.54-0.79).

Also, only patients who received specialist PC 3 to 6 months before death were significantly less likely to receive late chemotherapy than those who received late specialist PC (OR, 0.46; 95% CI, 0.24-0.88). However, patients who did not receive a specialist PC consultation were at the highest risk of receiving late chemotherapy (OR, 1.78; 95% CI, 1.30-2.42).

The researchers acknowledged their study’s limitations, one being using data solely on patients within Ontario, Canada. Consequently, their findings may not be generalizable to other health care jurisdictions. However, they expressed confidence in them, suggesting earlier PC initiation for optimized care quality.

"...early PC may be associated with less-aggressive EOL care than late palliative care,” the authors concluded. “Implementation strategies for early PC initiation are needed to optimize care quality and health resource utilization at the EOL.”

References

1. Mah SJ, Carter Ramirez DM, Schnarr K, Eiriksson LR, Gayowsky A, Seow H. Timing of palliative care, end-of-life quality indicators, and health resource utilization. JAMA Netw Open. 2024;7(10):e2440977. doi:10.1001/jamanetworkopen.2024.40977

2. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline update. J Clin Oncol. 2017;35(1):96-112. doi:10.1200/JCO.2016.70.1474