Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000-2006

Background: Quality of end-of-life care received by cancer patientshas never been explored in an entire Asian country for all agesand cancer groups. Patients and methods: Retrospective cohort study to examinetrends in quality of end-of-life care among a cohort of 242530 Taiwanese cancer patients who died in 2000–2006. Results: In the last month of life, cancer care tended to becomeincreasingly aggressive as shown by (i) intensive use of chemotherapy(15.45%–17.28%), (ii) frequent emergency room visits (15.69%–20.99%)and >14-day hospital stays (41.48%–46.20%), (iii) admissionsto intensive care units (10.04%–12.41%), and (iv) hospitaldeaths (59.11%–65.40%). Use of cardiopulmonary resuscitation(13.09%–8.41%), intubation (26.01%–21.07%), andmechanical ventilation (27.46%–27.05%) decreased, whereasuse of hospice services increased considerably (7.34%–16.83%).Among those receiving hospice services, rates of referrals tohospice services in the last 3 days of life decreased from 17.88%to 17.13% but remained steady after adjusting for selected covariates. Conclusions: The quality of end-of-life care for Taiwanese cancerdecedents was substantially inferior to that previously reportedand to that recommended as benchmarks for not providing overlyaggressive care near the end of life. Key words: administrative databases analysis, aggressiveness of care near the end of life, population-based study, quality of end-of-life care Received for publication May 7, 2008. Revision received July 25, 2008. Accepted for publication August 4, 2008.     

Proxy perspectives regarding end-of-life care for persons with cancer

BACKGROUND: Each year, greater than a half million people die of cancer in the U.S. Despite progress in increasing access to palliative oncology services, end-of-life care still needs improvement. Measuring the quality of the end-of-life experience is difficult because of patient debility and reduced consciousness as death approaches. Family proxies have been proposed as valuable informants regarding the quality of end-of-life care. This article describes family proxy perspectives concerning care at the end of life in patients who died of advanced cancer. METHODS: In the context of a novel outpatient palliative care demonstration project, 125 family proxy respondents completed a structured survey by telephone 3 months to 6 months after the patient's death from breast, lung, or gastrointestinal cancer. Four key quality of care indicators were measured: decision-making and physician communication, location of death, hospice involvement, and end-of-life symptoms. RESULTS: Proxies reported that 78% to 81% of patients completed at least 1 form of advance directive and approximately half of them were helpful in guiding care. Communication with physicians regarding end-of-life treatment wishes occurred in 67% of cases, but only 57% of the patients actually made a plan with their physician to ensure that their wishes were followed. The majority of patients died in their location of choice, most often at home, and greater than half had hospice involvement for an average of 41.8 days before death. During the last week of life, the majority of patients experienced troublesome physical and emotional symptoms. CONCLUSIONS: Measurement of proxy perspectives is feasible as an indicator of the quality of end-of-life care, and the results of the current study provide actionable data for areas of improvement in palliative oncology care.     

Toward population-based indicators of quality end-of-life care: testing stakeholder agreement

BACKGROUND: Quality indicators (QIs) are tools designed to measure and improve quality of care. The objective of this study was to assess stakeholder acceptability of QIs of end-of-life (EOL) care that potentially were measurable from population-based administrative health databases. METHODS: After a literature review, the authors identified 19 candidate QIs that potentially were measurable through administrative databases. A modified Delphi methodology, consisting of multidisciplinary panels of cancer care health professionals in Nova Scotia and Ontario, was used to assess agreement on acceptable QIs of EOL care (n = 21 professionals; 2 panels per province). Focus group methodology was used to assess acceptability among patients with metastatic breast cancer (n = 16 patients; 2 groups per province) and bereaved family caregivers of women who had died of metastatic breast cancer (n = 8 caregivers; 1 group per province). All sessions were audiotaped, transcribed verbatim, and audited, and thematic analyses were conducted. RESULTS: Through the Delphi panels, 10 QIs and 2 QI subsections were identified as acceptable indicators of quality EOL care, including those related to pain and symptom management, access to care, palliative care, and emergency room visits. When Delphi panelists did not agree, the principal reasons were patient preferences, variation in local resources, and benchmarking. In the focus groups, patients and family caregivers also highlighted the need to consider preferences and local resources when examining quality EOL care. CONCLUSIONS: The findings of this study should be considered when developing quality monitoring systems. QIs will be most useful when stakeholders perceive them as measuring quality care.     

Quality of End-of-Life Cancer Care in Canada: A 12-Year Retrospective Analysis of Three Provinces’ Administrative Health Care Data Evaluating Changes over Time

This retrospective cohort study of cancer decedents during 2004–2015 examined end-of-life cancer care quality indicators (QIs) in the provinces of British Columbia (BC), Ontario, and Nova Scotia (NS). These included: emergency department use, in-patient hospitalization, intensive care unit admissions, physician house calls, home care visits, and death experienced in hospital. Ontario saw the greatest 12-year decrease in in-hospital deaths from 52.8% to 41.1%. Hospitalization rates within 30 days of death decreased in Ontario, increased in NS, and remained the same in BC. Ontario’s usage of aggressive end-of-life measures changed very little, while BC increased their utilization rates. Supportive care use increased in both NS and Ontario. Those who were male or living in a lower income/smaller community (in Ontario) were associated with a decreased likelihood of receiving supportive care. Despite the shift in focus to providing hospice and home care services, approximately 50% of oncology patients are still dying in hospital and 11.7% of patients overall are subject to aggressive care measures that may be out of line with their desire for comfort care. Supportive care use is increasing, but providers must ensure that Canadians are connected to palliative services, as its utilization improves a wide variety of outcomes.     

Integration of Oncology and Palliative Care,a Forgotten Indicator: Shared Decision‐Making

A review article addressing the integration of oncology and palliative care is missing an important indicator: shared decision-making in patient care between oncologists and the palliative care team.Hui et al. [1] have published a review article addressing the integration of oncology and palliative care (PC). As described by the authors, integration is a heterogeneously defined concept, but since PC improves quality of life, quality of end-of-life care, satisfaction, costs of care, and survival, parameters to identify and improve integration are needed. This review identified 38 indicators related to structure and processes of clinical programs, education, research, and administration that could help define and measure integration. But we believe that the authors have missed one important indicator.In a case series study of metastatic cancer patients previously treated with chemotherapy, we studied the quality of end-of-life care [2] based on indicators such as location of death, number of emergency room visits in last month of life, and chemotherapy administration in last 14 days of life [3, 4]. In our study, PC team intervention, even when early, had no impact on indicators. Only patients’ case discussions at the dedicated weekly onco-palliative meetings independently decreased the odds of receiving chemotherapy in the last 14 days of life (odds ratio: 0.5; 95% confidence interval: 0.2–0.9) and of dying in an acute care setting (odds ratio: 0.3; 95% confidence interval: 0.1–0.5).In our opinion, this indicator is only partially captured by two indicators described in the review: communication, cooperation, and coordination between PC and oncology services (indicator 13); and involvement of PC in multidisciplinary tumor boards/patient care rounds (indicator 14). We propose that shared decision-making in patient care between oncologists and the PC team should be considered an indicator of integration of oncology and palliative care.     

Racial-Ethnic Disparities in End-of-Life Care Quality among Lung Cancer Patients: A SEER-Medicare–Based Study

Introduction

Cancer end-of-life care and associated racial-ethnic disparities have been in focus during the last few years due to concerns regarding subjective care variations and poor quality of care. Given the high mortality rate and disease burden of lung cancer, end-of-life care quality is particularly crucial for this disease. This study uses previously validated measures and examines racial-ethnic disparities in lung cancer end-of-life care quality.

Decrease in length of hospitalization before death of cancer patients in the Italian province of Imperia

Although the overall cure rates for cancer in Italy are comparable to those of other developed countries, these results are the product of very heterogeneous facilities. In order to assess the possible impact of improved acute cancer care services on the last phase of life, a retrospective study was carried out which included 4238 patients registered at the Division of Medical Oncology of Imperia Province from January 1995 to December 2002. In 1998 the Province of Imperia, with a population of 217,000, had only two doctors and five day-hospital beds. During 1999 and 2000, resources increased to include five oncology specialists and 10 day-hospital beds. Compared to 1998, in 2002 the number of new patients registering at the Division of Medical Oncology and the number of day-hospital treatments increased by 76% and 67%, respectively. Since end-of-life care for advanced cancer patients is expensive, the length of hospitalization of cancer patients dying in acute hospital settings was analyzed for the years 1995-2002. Of the 4238 patients registered during the eight-year period, 1433 (33.8%) died before 31 December 2002. Among these 1433 patients, the records relative to hospitalization and death were available for 571 cancer patients, 324 males (56.7%) and 247 females (43.3%) with a median age of 70 years (range, 21-91). The average number of days of hospitalization declined from 14.6 (range, 1-76) in 1998 to 8.2 (range, 1-29) in 2002, a decrease of approximately 44%. The length of hospitalization prior to death has declined considerably for cancer patients in the Imperia Province and the costs of acute hospital facilities for end-of-life care in cancer patients have decreased. In addition, fewer days in hospital before death may have had an important impact on the quality of life of these cancer patients.     

Quality of End-of-Life Care in Gastrointestinal Cancers: A 13-Year Population-Based Retrospective Analysis in Ontario,Canada

Population-based quality indicators of either aggressive or supportive care at end of life (EOL), especially when specific to a cancer type, help to inform quality improvement efforts. This is a population-based, retrospective cohort study of gastrointestinal (GI) cancer decedents in Ontario from 1 January 2006–31 December 2018, using administrative data. Quality indices included hospitalizations, emergency department (ED) use, intensive care unit admissions, receipt of chemotherapy, physician house call, and palliative home care in the last 14–30 days of life. Previously defined aggregate measures of both aggressive and supportive care at end of life were also used. In our population of 69,983 patients who died of a GI malignancy during the study period, the odds of experiencing aggressive care at EOL remained stable, while the odds of experiencing supportive care at EOL increased. Most of our population received palliative care in the last year of life (n = 65,076, 93.0%) and a palliative care home care service in the last 30 days of life (n = 45,327, 70.0%). A significant number of patients also experienced death in an acute care hospital bed (n = 28,721, 41.0%) or had a new hospitalisation in the last 30 days of life (n = 33,283, 51.4%). The majority of patients received palliative care in the last year of life, and a majority received a palliative care home service within the last 30 days of life. The odds of receiving supportive care at EOL have increased over time. Differences in care exist according to income, age, and rurality.     

End-of-Life Management in Pediatric Cancer

Pediatric palliative care at the end-of-life is focused on ensuring the best possible quality of life for patients with life-threatening illness and their families. To achieve this goal, important needs include: engaging with patients and families; improving communication and relationships; relieving pain and other symptoms, whether physical, psychosocial, or spiritual; establishing continuity and consistency of care across different settings; considering patients and families in the decision-making process about services and treatment choices to the fullest possible and desired degree; being sensitive to culturally diverse beliefs and values about death and dying; and responding to suffering, bereavement, and providing staff support. Any effort to improve quality of palliative and end-of-life care in pediatric oncology must be accompanied by an educational strategy to enhance the level of competence among health care professionals with regard to palliative care and end-of-life management skills as well as understanding of individualized care planning and coordination processes.     

Latent class analysis identifies three subtypes of aggressive end-of-life care: A population-based study in Taiwan

The aggressiveness of end-of-life (EOL) cancer care has often been analysed by the occurrence of several indicators, separately or aggregately. Whether aggressive EOL cancer care has different subtypes is unknown. This study sought to identify distinct subtypes of aggressive EOL care based on usage patterns of aggressive EOL-care indicators and to explore demographic, disease and treatment factors associated with the identified subtypes.This retrospective study linked data from 2001 to 2006 from three Taiwanese databases: National Registration of Death Database, Cancer Registration System and National Health Insurance claims database. Adult cancer patients (N = 203,642) who died in 2001–2006 were selected. For these cancer patients’ last month of life, we analysed eight indicators of aggressive EOL care: receiving chemotherapy, >1 emergency room visit, >1 hospitalisation, hospitalisation for >14 days, intensive care unit admission, received cardiopulmonary resuscitation, received intubation and received mechanical ventilation. Subtypes of aggressive EOL care were identified by latent class analysis.Among the study population, only 22.3% were treated by medical oncologists. Based on their profiles of EOL care, deceased cancer patients were classified into three subgroups: ‘not aggressive’ (45%), ‘intent to sustain life’ (33%) and ‘symptom crisis’ group (22%). Patients assigned to the ‘intent to sustain life’ group were less likely to have metastatic disease and to receive hospice care in the last year of life, but more likely to be cared for by non-medical oncologists, to die within 2 months after diagnosis and to die in hospital. EOL cancer care may be improved by understanding factors related to different subtypes of aggressive EOL care.     

Frühe palliative Intervention

Background

Many patients with metastatic lung cancer suffer from physical and psychological symptoms as well as of social and spiritual concerns. The goals of therapy are usually palliative. Factors like symptom control and quality of life are important in addition to prolonged survival in these circumstances. The randomised trial by Temel et al. presented here shows that early palliative care can reduce symptoms, improve quality of life and prolong survival.

Objectives

The effect of early palliative care on quality of life and end-of-life care among ambulatory patients with newly diagnosed metastatic lung cancer was evaluated.

Materials and methods

Patients with newly diagnosed metastatic lung cancer were randomised to treatment with standard therapy or standard therapy plus early palliative care. Quality of life and mood were assessed at baseline and at 12 weeks with the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale (HADS). The primary outcome was the change in quality of life at 12 weeks. The data of end-of-life care were collected from electronic medical records.

Results

The palliative care group had significantly better quality of life and less depression. The end-of-life care was less aggressive and hospice care was integrated earlier and more often. The survival time was significantly prolonged.

Conclusion

These data support the approach to integrate palliative care by a multiprofessional team early in the therapeutic concept for patients with newly diagnosed metastatic lung cancer.     

Attitudes of patients with incurable cancer toward medical treatment in the last phase of life.

PURPOSE: When cancer has advanced to a stage in which cure becomes unlikely, patients may have to consider the aim of further treatment. We studied the relationship of patients' attitudes toward treatment with advance care planning and the development of these attitudes after diagnosis of incurable cancer. PATIENTS AND METHODS: Patients with incurable cancer were interviewed and asked to fill out a written questionnaire about their attitudes concerning life-prolonging treatment and end-of-life decision making. These questions were repeated after 6 and 12 months. RESULTS: One hundred twenty-two patients (mean age, 64 years; standard deviation, 10.5 years; 53% women) participated in the study. Patients' attitudes toward treatment could be categorized into the following three different profiles: striving for quality of life, striving for length of life, and no clear preference. Patients who were older, more tired, or had less positive feelings and patients who had more often taken initiatives to engage in advance care planning were more inclined to strive for quality of life than others. Patients with a history of cancer of less than 6 months were more inclined to prefer life prolongation than patients with a longer history of cancer. During follow-up, no changes in attitudes toward treatment were found, except for patients with a short history of cancer in whom the inclination to strive for length decreased. CONCLUSION: Patients who appreciate advance care planning were more inclined to strive for quality of life than other patients. Shortly after the diagnosis of cancer, patients typically seem to prefer life-prolonging treatment, whereas quality of life becomes more important when death is nearing.     

Proposed agenda for the measurement of quality-of-care outcomes in oncology practice.

Cancer is an important disease, and health care services have the potential to improve the quality and quantity of life for cancer patients. The delivery of these services also has recently been well codified. Given this framework, cancer care presents a unique opportunity for clinicians to develop and test outcome measures across diverse practice settings. Recently, the Institute of Medicine released a report reviewing the quality of cancer care in the United States and called for further development and monitoring of quality indicators. Thus, as we move into the 21st century, professional and regulatory agencies will be seeking to expand process measures and develop and validate outcomes-oriented measures for cancer and other diseases. For such measures to be clinically relevant and feasible, it is key that the oncology community take an active leadership role in this process. To set the stage for such activities, this article first reviews broad methodologic concerns involved in selecting measures of the quality of care, using breast cancer to exemplify key issues. We then use the case of breast cancer to review the different phases of cancer care and provide examples of phase-specific measures that, after careful operationalization, testing, and validation, could be used as the basis of an agenda for measuring the quality of breast cancer care in oncology practice. The diffusion of process and outcome measures into practice; the practicality, reliability, and validity of these measures; and the impact that these indicators have on practice patterns and the health of populations will be key to evaluating the success of such quality-of-care paradigms. Ultimately, improved quality of care should translate into morbidity and mortality reductions.     

American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care

PURPOSE: An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to ASCO's membership following publication or presentation of potentially practice-changing data from major studies. This PCO addresses the integration of palliative care services into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. CLINICAL CONTEXT: Palliative care is frequently misconstrued as synonymous with end-of-life care. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. Although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services. By potentially improving quality of life (QOL), cost of care, and even survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available. RECENT DATA: Seven published RCTs form the basis of this PCO. PROVISIONAL CLINICAL OPINION: Based on strong evidence from a phase III RCT, patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care-when combined with standard cancer care or as the main focus of care-leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research. NOTE: ASCO's provisional clinical opinions (PCOs) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical trials and cannot be assumed to apply to the use of these interventions in the context of clinical practice. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO's PCOs, or for any errors or omissions.     

Palliative Care for Patients with Gynecologic Cancer in Japan:A Japan Society of Gynecologic Palliative Medicine (JSGPM) Survey

Purpose: To evaluate palliative care for patients with gynecologic cancer in Japan. Materials and Method: A questionnaire asking facility characteristics, systems to coordinate palliative care, current status of end-of-life care, provision of symptom relief, palliative radiation therapy and chemotherapy, and cases of death from gynecological cancer, was mailed to facilities treating gynecologic cancer. Results: A total of 115 facilities (29.3% of the total) responded to the questionnaire. Of these, 33.0 (29.0%) had a palliative care ward. End-of-life care was managed by obstetricians and gynecologists in 72.0% of the facilities. The site where end-of-life care was provided was most often a ward in the department where the respondent worked. The waiting period for transfer to a hospice was 2 weeks or more in 52% of facilities. Before the start of primary treatment, pain control was managed by obstetrians and gynecologists in 98.0% of facilities. Palliative radiation therapy or chemotherapy was administered at 93.9% and 92.0% of facilities, respectively. Of the 115 facilities, 34.0 (29.6%) reported cases of death from gynecological cancer. There were 1,134 cases of death. The median time between the last cycle of chemotherapy and death was 85 days for all gynecological cancers. The proportion of patients receiving chemotherapy in the last 30 and 14 days of life were 17.4% and 7.1%, respectively. Conclusions: This large-scale survey showed characteristics of palliative care given to patients with gynecologic cancer in Japan. Assessment of death cases showed that the median time between the last cycle of chemotherapy and death was relatively short.     

Trends in the aggressiveness of cancer care near the end of life.

PURPOSE: To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources. PATIENTS AND METHODS: We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program. RESULTS: Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P =.02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P <.001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P <.001), hospitalization (7.8% v 9.1%; P =.008), or were admitted to an intensive care unit (7.1% v 9.4%; P =.009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P <.001) and more used hospice services (28.3% v 38.8%; P <.001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P =.004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis. CONCLUSION: The treatment of cancer patients near death is becoming increasingly aggressive over time.     

End-of-life preferences in advanced cancer patients willing to discuss issues surrounding their terminal condition

MICCINESI G., BIANCHI E., BRUNELLI C. & BORREANI C. (2012) European Journal of Cancer Care21, 623-633 End-of-life preferences in advanced cancer patients willing to discuss issues surrounding their terminal condition The aim of the present study is to describe end-of-life preferences of advanced cancer patients willing to talk about death issues. Eighty-eight advanced cancer patients were interviewed through End of Life Preferences Interview (ELPI), a 23-item interview covering a wide range of end-of-life care issues. Most interviewed subjects were home care patients and their median survival after ELPI administration was 69 days. In total, 100% of responders expressed the will to receive some kind of information on the disease process and/or the treatments proposed. Approximately 77% declared to be willing to talk about what it is important at the end of life in case of worsening of their conditions and 31% prefer to be left alone in difficult moments. Approximately 67% choose home as the preferred place of death and 63% think it is preferable to die in a state of unconsciousness induced by drugs. About half of responders declare to believe in any kind of life after death and 40% consider very important to find any meaning at the end of life. ELPI can be a useful instrument to adapt the model of care to the specific needs and values of each patient.     

Validity of cancer registry data for measuring the quality of breast cancer care

BACKGROUND: Various groups have called for a national system to monitor the quality of cancer care. The validity of cancer registry data for quality of cancer care has not been well studied. We investigated the validity of such information in the California Cancer Registry. METHODS: We compared registry data associated with care with data abstracted from the medical records of patients diagnosed with breast cancer. We also calculated a quality score for each subject by determining the proportion of four evidence-based quality indicators that were met and then compared overall quality scores obtained from registry and medical record data. All statistical tests were two-sided. RESULTS: Records of 304 patients were studied. Compared with the medical record data gold standard, the accuracy of registry data was higher for hospital-based services (sensitivity = 95.0% for mastectomy, 94.9% for lumpectomy, and 95.9% for lymph node dissection) than for ambulatory services (sensitivity = 9.8% for biopsy, 72.2% for radiation therapy, 55.6% for chemotherapy, and 36.2% for hormone therapy). On average, quality scores calculated from registry data were 11 percentage points (95% confidence interval [CI] = 9 to 13 percentage points, P<.001) lower than those calculated from medical record data. Quality scores calculated from registry data were 5 percentage points (95% CI = 3 to 7 percentage points) lower for patients with stage I breast cancer, 16 percentage points (95% CI = 12 to 20 percentage points) lower for patients with stage II breast cancer, and 20 percentage points (95% CI = 8 to 32 percentage points) lower for patients with stage III breast cancer than were corresponding scores calculated from medical record data (all P<.001). The greater difference in quality scores for stage II and III patients revealed that disease severity and setting of care affected the validity of registry data. CONCLUSIONS: Cancer registry data for quality measurement may not be valid for all care settings, but registries could provide the infrastructure for collecting data on the quality of cancer care. We urge that funding be increased to augment data collection by cancer registries.     

Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects

BackgroundThe benefits and burdens of artificial nutrition (AN) and artificial hydration (AH) in end-of-life care are unclear. We carried out a literature review on the use of AN and AH in the last days of life of cancer patients.Materials and methodsWe systematically searched for papers in PubMed, CINAHL, PsycInfo and EMBASE. All English papers published between January 1998 and July 2009 that contained data on frequencies or effects of AN or AH in cancer patients in the last days of life were included.ResultsReported percentages of patients receiving AN or AH in the last week of life varied from 3% to 53% and from 12% to 88%, respectively. Five studies reported on the effects of AH: two found positive effects (less chronic nausea, less physical dehydration signs), two found negative effects (more ascites, more intestinal drainage) and four found also no effects on terminal delirium, thirst, chronic nausea and fluid overload. No study reported on the sole effect of AN.ConclusionsProviding AN or AH to cancer patients who are in the last week of life is a frequent practice. The effects on comfort, symptoms and length of survival seem limited. Further research will contribute to better understanding of this important topic in end-of-life care.