Access to palliative care for cancer patients between diagnosis and death: a national cohort study

Figures & data

Figure 1 Selection of study population flowchart.

Figure 2 Palliative care access for cancer patients included in the French Cancer Cohort who died between 2013 and 2015 by gender and according to each cancer site.

Figure 3 Cancer-related health care consumption between 2013 and 2015 according to palliative care access.

Table 1 Sociodemographic and medical characteristics of cancer patients included in the French Cancer Cohort who died between 2013 and 2015 (N=72,315)

	Total study population	Access to inpatient palliative care before death
	(Column %)	No (Column, %)	Yes (Column, %)
TOTAL (N, row %)	72,315 (100%)	31,374 (43%)	40,941 (57%)
Age in 2013 ^a
Age (mean [SD])	71.9 [14.1]	74.0 [13.8]	70.2 [14.2]
Age (median, [interquartile])	73.0 [62.0–83.0]	76.0 [64.0–85.0]	71.0 [61.0–81.0]
Age in 2013
<18 years	218 (0%)	64 (0%)	154 (0%)
18–49	3,974 (5%)	1,236 (4%)	2,738 (7%)
50–74	33,764 (47%)	13,218 (42%)	20,546 (50%)
75 years and older	34,359 (48%)	16,856 (54%)	17,503 (43%)
Gender
Men	42,195 (58%)	18,766 (60%)	23,429 (57%)
Women	30,120 (42%)	12,608 (40%)	17,512 (43%)
Cancer site
Gastrointestinal	21,475 (30%)	8,479 (27%)	12,996 (32%)
Multiple sites	8,888 (12%)	3,088 (10%)	5,800 (14%)
Non-attributable sites	2,645 (4%)	1,606 (5%)	1,039 (2%)
Respiratory	14,914 (21%)	5,495 (18%)	9,419 (23%)
Endocrine glands	229 (0%)	117 (0%)	112 (0%)
Hematological	4,604 (6%)	2,698 (9%)	1,906 (5%)
Eye	42 (0%)	19 (0%)	23 (0%)
Female genitals	2,373 (3%)	839 (3%)	1,534 (4%)
Male genitals	2,267 (3%)	1,401 (4%)	866 (2%)
Bone	116 (0%)	46 (0%)	70 (0%)
Skin	2,831 (4%)	2,015 (6%)	816 (2%)
Breast	2,625 (4%)	1,461 (5%)	1,164 (3%)
Nervous system	2,088 (3%)	625 (2%)	1,463 (4%)
Soft tissues	133 (0%)	77 (0%)	56 (0%)
Upper aerodigestive tract	3,153 (4%)	1,512 (5%)	1,641 (4%)
Urinary tract	3,932 (6%)	1,896 (6%)	2,036 (5%)
Cancer stage in 2013
In situ	309 (1%)	250 (1%)	59 (0%)
Invasive	36,933 (51%)	19,164 (61%)	17,769 (43%)
Lymph node involvement	3,857 (5%)	1,578 (5%)	2,279 (6%)
Metastatic	29,772 (41%)	9,221 (29%)	20,551 (50%)
Non-attributable	1,444 (2%)	1,161 (4%)	283 (1%)
Comorbidities in 2013
None	18,499 (26%)	6,537 (21%)	11,962 (29%)
1	24,867 (34%)	10,681 (34%)	14,186 (35%)
≥2	28,949 (40%)	14,156 (45%)	14,793 (36%)
Area-level degree of social deprivation
1 - Very low (first quintile)	11,798 (16%)	4,885 (16%)	6,913 (17%)
2 - low (second quintile)	12,744 (18%)	5,415 (18%)	7,329 (19%)
3 - Average (third quintile)	13,946 (19%)	6,254 (21%)	7,692 (19%)
4 - High (fourth quintile)	14,781 (20%)	6,495 (21%)	8,286 (21%)
5 - Very high (fifth quintile)	16,524 (23%)	7,215 (24%)	9,309 (24%)
Missing	2,522 (4%)	1,110 (.%)	1,412 (.%)
Region
Auvergne-Rhône-Alpes	8,034 (11%)	3,213 (10%)	4,821 (12%)
Bourgogne-Franche-Comté	3,356 (5%)	1,631 (5%)	1,725 (4%)
Bretagne	3,317 (5%)	1,578 (5%)	1,739 (4%)
Centre-Val de Loire	3 029 (4%)	1,300 (4%)	1,729 (4%)
Corse	313 (0%)	121 (0%)	192 (0%)
Départements d’Outre-Mer (DOM)/Territoires d’Outre-Mer (TOM)	1,523 (2%)	696 (2%)	827 (2%)
Grand Est	6,577 (9%)	2,831 (9%)	3,746 (9%)
Hauts-de-France	7,307 (10%)	3,072 (10%)	4,235 (10%)
Île-de-France (IDF)	11,294 (16%)	4,451 (14%)	6,843 (17%)
Normandie	4,302 (6%)	1,862 (6%)	2,440 (6%)
Nouvelle Aquitaine	6,584 (9%)	2,967 (10%)	3,617 (9%)
Occitanie	5,833 (8%)	2,685 (9%)	3,148 (8%)
Pays-de-la-Loire	3,847 (5%)	1,734 (6%)	2,113 (5%)
Provence-Alpes-Côte d’Azur (PACA)	6,005 (8%)	2,858 (9%)	3,147 (8%)
Unknown	994 (2%)	375 (1%)	619 (2%)

Note: ^aAge was summarized using mean [SD] and median [IQR].

Table 2 Factors independently associated with PC access. Multivariable logistic regressions

	Adjusted odds ratios [95% confidence interval]
	Access to inpatient palliative care before death vs no access
	Total	Men	Women
Gender (ref. men)
Women	1.15 [1.11–1.20]***	-	-
Age in 2013 (ref. 50–74 years)
18–49 years	1.38 [1.26–1.51]***	1.34 [1.21–1.47]***	1.36 [1.21–1.54]***
75 years and older	0.88 [0.84–0.91]***	0.89 [0.85–0.93]***	0.82 [0.78–0.87]***
<18 years	1.77 [1.20–2.62]**	1.74 [1.10–2.76]*	1.50 [0.93–2.41]
Cancer site (ref. respiratory system)
Gastrointestinal	1.00 [0.96–1.05]	1.05 [0.99–1.11]	0.94 [0.86–1.02]
Non-attributable sites	-	0.55 [0.48–0.63]***	0.46 [0.39–0.53]***
Multiples sites	-	1.15 [1.07–1.24]***	1.07 [0.97–1.18]
Endocrine glands	0.57 [0.43–0.75]***	0.55 [0.36–0.86]**	0.56 [0.39–0.79]**
Male genitals	-	0.54 [0.48–0.59]***	-
Hematologic	0.62 [0.58–0.67]***	0.67 [0.61–0.74]***	0.58 [0.52–0.65]***
Female genitals	-	-	0.95 [0.85–1.06]
Bone	0.88 [0.59–1.31]	0.86 [0.49–1.51]	0.89 [0.51–1.55]
Skin	0.37 [0.34–0.41]***	0.44 [0.39–0.50]***	0.31 [0.27–0.36]***
Breast	-	0.43 [0.20–0.93]*	0.49 [0.44–0.55]***
Nervous system	1.80 [1.62–2.01]***	2.29 [1.98–2.65]***	1.41 [1.20–1.65]***
Soft tissues	0.52 [0.36–0.74]***	0.50 [0.30–0.84]**	0.51 [0.31–0.86]*
Upper aerodigestive tract	0.81 [0.74–0.88]***	0.82 [0.75–0.90]***	0.83 [0.70–1.00]*
Urinary tract	0.82 [0.76–0.89]***	0.80 [0.73–0.88]***	0.91 [0.79–1.04]
Eye	0.96 [0.51–1.80]	1.15 [0.51–2.59]	0.78 [0.28–2.13]
Cancer stage (ref. invasive)
Lymph node	1.33 [1.23–1.45]***	1.42 [1.30–1.56]***	1.40 [1.25–1.57]***
Metastatic	2.04 [1.96–2.13]***	2.13 [2.03–2.23]***	2.16 [2.04–2.28]***
In situ	0.31 [0.22–0.44]***	0.36 [0.24–0.55]***	0.37 [0.24–0.56]***
Non-attributable	0.17 [0.10–0.28]***	0.44 [0.36–0.54]***	0.46 [0.37–0.58]***
Comorbidities in 2013 (ref. no comorbidities)
1	0.82 [0.78–0.86]***	0.82 [0.77–0.87]***	0.76 [0.71–0.81]***
≥2	0.69 [0.66–0.73]***	0.70 [0.67–0.74]***	0.61 [0.58–0.65]***
Area-level degree of social deprivation (ref. very high deprivation)
Very low deprivation	1.06 [1.00–1.13]	1.03 [0.96–1.11]	1.04 [0.96–1.14]
Low deprivation	1.09 [1.03–1.15]**	1.08 [1.01–1.16]*	1.01 [0.94–1.10]
Average deprivation	1.03 [0.97–1.09]	0.97 [0.91–1.03]	1.03 [0.95–1.12]
High deprivation	1.04 [0.98–1.09]	1.04 [0.97–1.10]	0.97 [0.89–1.04]
Regions (ref. Île-de-France (IDF))
Auvergne-Rhône-Alpes	1.00 [0.93–1.08]	0.98 [0.90–1.06]	1.04 [0.94–1.15]
Bourgogne-Franche-Comté	0.68 [0.61–0.75]***	0.62 [0.56–0.70]***	0.80 [0.69–0.90]***
Bretagne	0.72 [0.65–0.79]***	0.66 [0.60–0.74]***	0.82 [0.72–0.94]**
Centre-Val de Loire	0.88 [0.79–0.97]*	0.89 [0.79–1.00]*	0.86 [0.75–0.99]*
Corse	1.08 [0.19–5.97]	1.47 [0.15–14.57]	0.77 [0.11–5.50]
Départements d’Outre-Mer (DOM)/ Territoires d'Outre-Mer (TOM)	0.56 [0.24–1.30]	0.27 [0.10–0.74]*	1.31 [0.44–3.90]
Grand Est	0.84 [0.77–0.91]***	0.85 [0.77–0.93]***	0.89 [0.80–0.99]*
Hauts-de-France	0.89 [0.82–0.96]**	0.89 [0.81–0.97]**	0.97 [0.87–1.08]
Unknown	0.83 [0.70–0.97]*	0.83 [0.70–0.98]*	0.95 [0.72–1.27]
Normandie	0.90 [0.82–0.99]*	0.86 [0.77–0.95]**	0.92 [0.81–1.04]
Nouvelle Aquitaine	0.80 [0.74–0.86]***	0.79 [0.72–0.87]***	0.82 [0.74–0.91]***
Occitanie	0.74 [0.68–0.80]***	0.74 [0.68–0.81]***	0.79 [0.71–0.88]***
Pays-de-la-Loire	0.79 [0.72–0.87]***	0.74 [0.67–0.83]***	0.90 [0.79–1.02]
Provence-Alpes-Côte d’Azur (PACA)	0.75 [0.69–0.81]***	0.75 [0.69–0.82]***	0.76 [0.68–0.84]***

Notes: Multivariable logistic regressions were selected by forward stepwise selection procedure using all the variables presented in Table 1 (probability threshold=20%, probability of staying in the model=5%)

Multivariable logistic regressions were carried out in three different groups: “Total” where only common cancer sites to both women and men were considered (51,835), “Men” where cancer sites specific to men were included, plus non-attributable cancer sites and multiple-site cancer (N=40,800), and “Women” where cancer sites specific to women were included, plus non-attributable sites and multiple-site cancer (N=28,993).

*p<0.05; **p<0.01; ***p<0.001

Table 3 Time between initial palliative care access and death, cancer diagnosis and death, and diagnosis and palliative care access (N=40,941)

	Mean [SD] ^a	Median [interquartile] ^a
From diagnosis to death (days)	271.7 [205.4]	231.0 [87.0–427.0]
From diagnosis to palliative care access (days)	206.5 [198.6]	144.0 [32.0–344.0]
From palliative care access to death (days)	65.3 [100.4]	29.0 [13.0–67.0]

Note: ^aTime intervals were summarized using mean [SD] and median [IQR]