Rehabilitation and palliative care for socioeconomically disadvantaged patients with advanced cancer: a scoping review

Figures & data

Table 1. Search strategy for the scoping review.

Inclusion criteria	Publication years 2009–2019 Peer-reviewed publication Studies of any design English, Danish, Norwegian or Swedish language Adults (>18 years of age) diagnosed with advanced cancer (metastatic cancer, incurable cancer or cancer stage III and IV) “Socioeconomically vulnerable” defined by low socioeconomic status/position (income, educational level, occupational status) Rehabilitation/palliative care (e.g., physical training, psycho-educative interventions, self-management, special aids)
Exclusion criteria	Gray literature, editorials/commentaries, guidelines, letters, conference abstracts Socially vulnerable defined by race/ethnicity, age, comorbidity, etc. Medical, surgical or invasive technology interventions
PubMed search string (final version)	(((Malignancy[Title/Abstract]) OR Malignancies[Title/Abstract]) OR Malignant[Title/Abstract]) OR Malign[Title/Abstract]) OR metastatic[Title/Abstract]) OR metastas*[Title/Abstract]) OR Incurable cancer*[Title/Abstract]) OR Advanced cancer*[Title/Abstract]) OR Advanced neoplasm*[Title/Abstract]) OR Chronic Cancer*[Title/Abstract]) OR Stage 3 cancer*[Title/Abstract]) OR Stage III Cancer*[Title/Abstract]) OR Stage 4 Cancer*[Title/Abstract]) OR Stage IV Cancer*[Title/Abstract] AND (((Socioeconomic factors[Mesh]) OR Economic Status*[Title/Abstract]) OR Social Class*[Title/Abstract]) OR Social mobilit*[Title/Abstract]) OR Health Literac*[Title/Abstract]) OR Unemploy*[Title/Abstract]) OR Employment Status*[Title/Abstract]) OR Social Conditions[Mesh]) OR Social Condition*[Title/Abstract]) OR Low-Income*[Title/Abstract]) OR Inequalit*[Title/Abstract]) OR Equalit*[Title/Abstract]) OR Socio-economic factor*[Title/Abstract]) OR Socioeconomic factor*[Title/Abstract]) OR Social Marginalization[Mesh]) OR Social Marginalization[Title/Abstract]) OR Equity[Title/Abstract]) OR Inequit*[Title/Abstract]) OR Healthcare Disparit*[Title/Abstract]) OR Healthcare Disparities[Mesh]) OR Vulnerable populations[mesh]) OR health status disparities[mesh]) OR underserved patient*[Title/Abstract]) OR Health disparit*[Title/Abstract]) OR Family Health[MeSH]) OR Cohabitation*[Title/Abstract]) OR Low education*[Title/Abstract]) OR Lower education*[Title/abstract]) OR Family characteristics[MeSH] OR Living Alone[Title/Abstract]) OR Civil Status[Title/Abstract] AND (((Rehabilitation Research[Mesh]) OR Rehabilitation[Mesh]) OR Rehabilitation[Title/Abstract]) OR Rehabilitations[Title/Abstract]) OR Exercise Therapy[Title/Abstract]) OR Exercise Therapies[Title/Abstract]) OR Rehabilitative[Title/Abstract]) OR Aftercare[Mesh:noexp]) OR After Care[Title/Abstract]) OR After-Treatment*[Title/Abstract]) OR Follow-Up Care*[Title/Abstract]) OR Recovery of Function[MeSH]) OR Function Recover*[Title/Abstract]) OR Survivorship[Mesh]) OR Health Education[Mesh]) OR Patient Education*[Title/Abstract]) OR Late-effect[Title/Abstract]) OR Late-effects[Title/Abstract] OR Cancer rehabilitation[Title/Abstract] OR (((Hospices[Mesh]) OR Hospice[Title/Abstract]) OR Hospices[Title/Abstract]) OR Palliative Care[Mesh]) OR (Hospice and Palliative Care Nursing[Mesh])) OR Long-Term Care[Mesh]) OR Long Term Care[Title/Abstract]) OR Terminal Care[Mesh]) OR Terminal Care[Title/Abstract]) OR End of Life[Title/Abstract]) OR Palliation[Title/Abstract]) OR Palliative[Title/Abstract]) OR Palliative Medicine[Mesh]) OR Terminal ill*[Title/Abstract]) OR Terminally ill[Title/Abstract] OR Home health nursing[Mesh] OR Advanced home care[Title/Abstract]

Figure 1. Flowchart of included and excluded articles.

Table 2. Findings from the included articles (N = 11).

First author, year (reference #)	Country	Number	Cancer type	Age (mean)	Female (%)	Study aim	Study design	Determinants of socioeconomic status	Findings related to socioeconomic status and rehabilitation and/or palliative care	Topic (rehabilitation and/or palliative care)
Rubens et al. [31]	USA	389,417 hospitalizations	Mixed advanced cancer types	n/a	54	To explore the characteristics of palliative care utilization among hospitalized patients with advanced cancers using National Inpatient Sample (NIS) data which prove a nationally representable sample. In addition, look for factors associated with palliative care utilization in these patients	Register study	Income: median household income by zip code (quartiles) Education: n/a Occupation: n/a	Estimates related to income: Palliative care consultations were significantly higher in the fourth income quartiles (OR: 1.08; 95% CI: 1.01–1.17) than in the first quartile. They were also higher in the second and third quartiles, though not significantly so Estimates related to education: n/a Estimates related to occupation: n/a Summary: High income was associated with higher palliative care consultations	Palliative care
Santos Salas et al. [39]	Canada	11 palliative care providers, including registered nurses, nurse practitioners, physicians and pharmacists	Mixed cancer types	n/a	n/a	To investigate palliative care practitioners' perspectives on how the Social Determinants of Health affect the symptom experience of populations with advanced cancer, and to outline practice strategies with populations with social disparities to enhance symptom relief	Two sequential qualitative studies	Income: n/a Education: n/a Occupation: n/a The study was informed by the Social Determinants of Health framework (Whitehead and Dahlgren 2006)	Estimates related to income: n/a Estimates related to education: n/a Estimates related to occupation: n/a Summary: Participants’ stories revealed the complex interactions of the Social Determinants of Health affecting patients’ ability to deal with their symptoms due to lack of financial resources, lack of education or other personal circumstances The impact of income on patients’ experiences was acknowledged by participants. They recalled situations where both low and high income affected patients’ ability to deal with their illness. Low income and financial constraints were commonly perceived as barriers Participants perceived that both educational level and intellectual issues might affect the patient’s ability to understand symptom control. While the degree to which education affects symptom complexity cannot be determined, limited education emerged as a contributing factor No results on the second part of the aim are offered in the article	Palliative care
Schuurhuizen et al. [40]	Netherlands	349 patients	Metastatic colorectal cancer	64.8	37	To identify predictors for the use of psychosocial services in patients with metastatic colorectal cancer (mCRC) receiving first-line chemotherapy enrolled in a prospective cluster-randomized trial (CRT)	Secondary analysis of data from a prospective cluster-randomized trial	Income: n/a Education: level (low, middle, high) (categorical) Occupation: working/not working (binary)	Estimates related to income: n/a Estimates related to education: In the univariate analyses, education at baseline was significantly associated with the use of psychosocial support (p-value: 0.04). In the logistic regression analysis, use of psychosocial service was significantly associated with a higher educational level (p-value: 0.05)*. Estimates related to occupation: Occupation at baseline was not significantly associated with the use of psychosocial support (p-value: 0.95). *A 0.10 significance level is applied in the study Summary: Use of psychosocial services was associated with a higher educational level. There were no differences for employment at baseline	Palliative care
Forst et al. [32]	USA	12,437 patients	Malignant glioma (brain tumour)	69.9	46	To evaluate the rates and correlates of hospice use among patients with malignant glioma; and to describe the proportion of malignant glioma patients enrolled in hospice and their length of stay in hospice. The authors also aimed to identify predictive factors for overall hospice enrollment and hospice length of stay	Register study	Income: median household income by zip code (continuous variable) Education: Percentage of adults age ≥25 y with a high school education by zip code Occupation: n/a	Estimates related to income: The odds of hospice enrollment were lower with increasing household income (OR: 0.9; 95% CI: 0.85–0.94). Household income was not associated with length of stay in hospice Estimates related to education: The odds of hospice enrollment prior to death were higher for patients who were better educated (OR: 1.20; 95% CI: 1.08–1.23). Education was not associated with length of stay in hospice. Estimates related to occupation: n/a Summary: The odds of hospice enrollment prior to death were higher for patients who were better educated, and lower with increasing household income	Palliative care
Rosenfeld et al. [37]	USA	67,947 patients	Gynecologic cancer	63	100	To determine the factors associated with inpatient palliative care use in patients with metastatic gynecologic cancer	Register study	Income: median household income by zipcode was categorized by socioeconomic status (quartiles) Education: n/a Occupation: n/a	Estimates related to income: Patients of the following socioeconomic status used palliative care: 4.5% of low, low–middle, and middle–high; and 5.1% of high. No significance was found for socioeconomic status as a parameter associated with palliative care (p-values ranged 0.17–0.85) Estimates related to education: n/a Estimates related to occupation: n/a Summary: Socioeconomic status was not a statistically significant independent predictor of inpatient palliative care utilization	Palliative care
Saeed et al. [38]	USA	383 patients	Mixed cancer types	65 years: 50% <65 years: 50% Mean age not provided for subgroup	55	To test the hypothesis that men and those with lower levels of educational attainment have less favorable attitudes toward palliative care.	Cross-sectional study	Income: assessed by two proxies for economic burden: insurance status (Medicaid or no insurance vs. Medicare or private insurance), and perceived financial strain (present or absent) Education: high school vs. some college (binary) Occupation: n/a	Estimates related to income: Economic burden was used to adjust analyses. Estimates related to education: the effect of education on preferences for palliative care was not statistically significant (OR: 0.85; 95% CI: 0.48–1.48). Similar findings were observed in the sensitivity analysis (OR: 0.69; 95% CI: 0.38–1.26) and the ordinal regression model (OR: 1.06; 95% CI: 0.69–1.63). Estimates related to occupation: n/a Summary: The hypothesis about education having an influence of palliative care preferences was not supported. Preferences for palliative care were comparable among participants with a high school education or less and those with more education	Palliative care
Okafor et al. [30]	USA	30,150 hospitalizations	Mixed cancer types	n/a	54	To explore patient- and hospital-level determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal tract cancer using a national database	Register study	Income: median household income by zip code (quartiles) Education: n/a Occupation: n/a	Estimates related to income: No significant socioeconomic differences in inpatient palliative care utilization were identified (p-values across quartiles ranged: 0.38–0.93) Estimates related to education: n/a Estimates related to occupation: n/a Summary: No significant socioeconomic differences in inpatient palliative care utilization were identified	Palliative care
Penrod et al. [36]	USA	3096 patients	Mixed cancer types	60.2	56	To identify characteristics of hospitalized advanced cancer patients that are associated with referral to an interdisciplinary hospital-based palliative care team	Multicenter prospective observational study	Income: n/a Education: more than high school / high school or less (binary) Occupation: n/a	Estimates related to income: n/a Estimates related to education: No significant association between education and likelihood of referral to palliative consultation team (more than high school education (OR: 0.89; 95% CI:0.72–1.10)) Estimates related to occupation: n/a Summary: The study found no evidence that education was associated with the likelihood of referral to palliative consultation team. No evidence of socio- demographic differences in palliative care likelihood within sites was found	Palliative care
Mack et al. [34]	USA	52,710 patients	Lung cancer	Two groups: 1) 21–64 2) ≥ 65 Means not provided for subgroups	46	To evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare	Register study	Income: median household income by zip code (quartiles) Education: n/a Occupation: n/a	Estimates related to income: The odds of hospice use were lower in the older (≥65 years), low-income group than in the older (≥65 years), high-income group when stratifying for location (California and New York) (OR: 0.83; 95% CI: 0.77–0.90) and (OR: 0.82; 95% CI: 0.75–0.90). This was also found in patients between 55 and 74 years old. Here, the high-income group had higher odds for using hospice than the low-income patients when stratifying for location (California and New York) (OR: 1.30; 95% CI: 1.16–1.46) and (OR: 1.25; 95% CI: 1.08–1.45) The odds for using hospice was less clear when comparing the low-income group with the high-income group (reference group) in patients between 21–64 years old when stratifying for location (California and New York) (OR: 1.25; 95% CI: 1.02–1.64) and (OR: 0.99; 95% CI: 0.75–1.33) Estimates related to education: n/a Estimates related to occupation: n/a Summary: Low-income patients had lower odds for using hospice than high-income patients. This primarily included the older age group (≥ 55 years)	Palliative care
Maddison et al. [35]	Canada	1201 patients	Colorectal cancer	72.2	47	To examine inequalities in access to and quality of EOL care by assessing registration in a palliative care program, emergency room visits in the last 30 days of life and location of death among individuals who died of colorectal cancer in Nova Scotia, Canada, between 2001 and 2008	Register study	Income: median household income by zip code (three categories: <$30,000; $30,000–44,999; $45,000+) Education: n/a Occupation: n/a	Estimates related to income: Patients with an annual income of more than $45,000 had 2.74 times greater odds (95 % CI: 1.1–6.9) of registering in a palliative care program than individuals with incomes of under $30,000. This was not statistically significant among those diagnosed with stage IV colorectal cancer. Estimates related to education: n/a Estimates related to occupation: n/a Summary: Patients with low incomes are at a higher likelihood of not registering in a palliative care program, while income appears to be less influential among those diagnosed with stage IV colorectal cancer	Palliative care
Lyckholm et al. [33]	USA	29 patients 34 healthcare providers	Mixed cancer types	Patients: 56 Healthcare providers: 41	n/a	To identify barriers to good end-of-life care in low-income patients with late stages of cancer	Observational study (pilot) combined with a literature review	Income: low income (undefined) Education: n/a Occupation: n/a	Estimates related to income: n/a Estimates related to education: n/a Estimates related to occupation: n/a Summary: Providers thought hospice was discussed more often than did patients Patients differed considerably from health care providers in their perceptions of barriers to good care. Healthcare providers overestimated the barriers perceived by patients. The particular issues identified by medical personnel as barriers included transportation, insurance, unsafe neighborhood for hospice nurse visits and reluctance to discuss health issues with healthcare providers. None of these were perceived as barriers by the patients Even experienced healthcare providers cannot predict barriers to better care perceived by patients—it is imperative to ask each patient specifically about barriers to adequate palliative care	Palliative care

Rubens M, Ramamoorthy V, Saxena A, et al. Palliative care consultation trends among hospitalized patients with advanced cancer in the United States, 2005 to 2014. Am J Hosp Palliat Care. 2019;36(4):294–301.

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Santos Salas A, Watanabe SM, Tarumi Y, et al. Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives. Support Care Cancer. 2019;27(12):4733–4744.

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Schuurhuizen C, Braamse AMJ, Konings I, et al. Predictors for use of psychosocial services in patients with metastatic colorectal cancer receiving first line systemic treatment. BMC Cancer. 2019;19(1):115.

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Forst D, Adams E, Nipp R, et al. Hospice utilization in patients with malignant gliomas. Neuro-Oncology. 2018;20(4):538–545.

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Rosenfeld EB, Chan JK, Gardner AB, et al. Disparities associated with inpatient palliative care utilization by patients with metastatic gynecologic cancers: a study of 3337 women. Am J Hosp Palliat Care. 2018;35(4):697–703.

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Saeed F, Hoerger M, Norton SA, et al. Preference for palliative care in cancer patients: are men and women alike? J Pain Symptom Manage. 2018;56(1):1–6.e1.

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Okafor PN, Stobaugh DJ, Nnadi AK, et al. Determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal malignancies. Am J Hosp Palliat Care. 2017;34(3):269–274.

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Penrod JD, Garrido MM, McKendrick K, et al. Characteristics of hospitalized cancer patients referred for inpatient palliative care consultation. J Palliat Med. 2017;20(12):1321–1326.

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Mack JW, Chen K, Boscoe FP, et al. Underuse of hospice care by Medicaid-insured patients with stage IV lung cancer in New York and California. J Clin Oncol. 2013;31(20):2569–2579.

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Maddison AR, Asada Y, Burge F, et al. Inequalities in end-of-life care for colorectal cancer patients in Nova Scotia. J Palliat Care. 2012;28(2):90–96.

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Lyckholm LJ, Coyne PJ, Kreutzer KO, et al. Barriers to effective palliative care for low-income patients in late stages of cancer: report of a study and strategies for defining and conquering the barriers. Nurs Clin North Am. 2010;45(3):399–409.

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