A study concluding that there was no clear association between the survival rates of advanced cancer patients and the amount that Medicare spent on their care suggests that more doctors should be looking to health care delivery models that focus on palliative, patient-centered care rather than aggressive interventions, health care observers said.
“Improvements in outcomes for patients with advanced cancer have been limited,” stated the study, which was published online in the Journal of the National Cancer Institute on March 12. New therapies for those with advanced cancer often are very expensive but extend the patient's life by only weeks or months. Other studies looking at regional differences in medical spending have not always found improved outcomes when spending is higher.
To assess a possible correlation between medical spending and survival rates, Gabriel Brooks, MD, a medical oncology fellow with the Dana-Farber Cancer Institute, and fellow researchers examined both Medicare claims data and information from the National Cancer Institute's Surveillance, Epidemiology and End Results, or SEER, database. More than 116,000 subjects 65 and older either were in the advanced stages of certain cancers or had died from them, had been diagnosed with cancer between 2002 and 2007, and were drawn from 80 hospital referral regions designated by the SEER database.
For this study, researchers discovered significant regional differences in what the program spent on advanced cancer care. Those in higher-spending regions were more likely to end up in the intensive care units of hospitals or receive aggressive end-of-life treatments than those in lower-spending areas. However, there was no consistent link between what a region spent on this type of care and the survival rates of patients in that region.
The results aren't surprising, said Stephen Finan, senior director of policy with the American Cancer Society Cancer Action Network. It long has been recognized that more money spent on this care does not correlate with a longer or better quality of life, he said.
A common story is that of a patient receiving chemotherapy on the day he or she dies, Finan said, and it's a sign of a “full speed ahead no matter what” approach to care. In some cases, this may be what the patient wants, but it's also possible that he or she might not be making an informed decision, or might not be aware of alternatives, he added.
Patient demand also is driving some doctors to order MRIs or fourth-line chemotherapy treatments, said Peter Bach, MD, who recently spoke at an ACS CAN forum in Washington on health care delivery reforms and chronic disease. “Although I'm completely an advocate for individual patients playing an important role in their care, we can't come to a point where doctors and other health care professionals are abdicating their primary responsibilities. So my view is, if a patient demands a chest x-ray that I don't think is in their best interest, I shouldn't order it.” Dr. Bach is an attending physician at the epidemiology and bio-statistics health outcomes department at Memorial Sloan-Kettering Cancer Center in New York, but he spoke as an individual at the forum.
Finan offered the view that patients need to become better educated “so when they face a particularly serious condition like advanced stage cancer … they ask questions about their treatments, what the treatment options are, what the likely consequences are and what is best for their needs.”
The journal study reinforced the fact that Medicare's current fee-for-service model, which pays physicians based on volume and not patient outcomes, “is not getting us where we need to be, and that reforms which emphasize best practices and health outcomes and survivor-ship is where we need to go,” he said.
In discussing the findings, the study's authors recommended that health care professionals aim to reduce potentially unnecessary hospitalizations while ramping up access to palliative care for patients with advanced-stage cancer, an approach that focuses on quality of life and pain relief. These goals are “consistent with patient-centered care,” the study concluded.
As a person living with Stage IV breast cancer, Amy Berman, RN, another speaker at the ACS CAN forum, said the palliative care model provides an extra layer of support for people with serious illnesses who otherwise might experience unnecessary pain and other symptoms that accompany interventional treatments. She is a senior program officer for the John A. Hartford Foundation, a New York-based philanthropic organization that focuses on aging and health.
Palliative care also has huge cost implications for Medicare and other payers, as “it keeps patients out of places they don't want to be,” Berman said. For some people, the health care goal may be to stay at home and maintain their quality of life instead of being hospitalized, she said.
The key is to integrate palliative care early on in conversations with advanced cancer patients, said Sandra Swain, MD, president of the American Society of Clinical Oncology. She also is the medical director of the Washington Cancer Institute at MedStar Washington Hospital Center. Part of the problem is that oncologists haven't always been doing this at the beginning of Stage IV cancer diagnoses.
As a result, she said, “we're spending all of this money at the end, when the survival rate is not improving and the quality of life is less” because people die in the intensive care unit where they can't be close to their families. “They really can't have a peaceful death.”
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