Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan

Abstract

Background

Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.

Methods

All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.

Results

During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20–2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38–3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48–6.38, p = 0.0027). Fewer patients in the “no referral” group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).

Conclusion

Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.

Keywords:

• metastatic breast cancer
• palliative care
• end-of-life
• Do not resuscitate
• DNR

Data Sharing Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics Declarations

The study was approved by the Institutional Review Board (IRB) at King Hussein Cancer Center (approval number: 19 KHCC 64), and all procedures were performed based on the regulations of the Declaration of Helsinki. Given the retrospective nature of the study and lack of patients’ identifiers, consent to participate was waived by the IRB.

Consent for Publication

Data submitted are entirely unidentifiable, and there are no details on individuals reported within the manuscript.

Acknowledgments

The abstract of this paper was presented in-part at the annual meeting of the European Society of Medical Oncology (ESMO) held on 16-21 September, 2021 as a poster presentation with interim findings.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declared that they have no conflicting interest in this work.

Additional information

Funding

This research was not funded.