Study Reveals Disparities in End-of-Life Care Among Ovarian Cancer Patients

Jolyn S. Taylor, MD

Within the last 30 days of life, black and Latina women with ovarian cancer were less likely than white women to enroll in hospice care, according to results recently published in the Journal of Clinical Oncology.

Additionally, white women were less likely to undergo more intensive care in the last month of life, to be admitted to the ICU, have more than 1 emergency room (ER) visit, undergo life-extending care, and undergo invasive care.

“Our analysis confirmed that, irrespective of other sociodemographic factors, patients of black and Hispanic racial and ethnic backgrounds were less likely to meet end-of-life quality-care metrics,” lead researcher Jolyn S. Taylor, MD, University of Texas MD Anderson Cancer Center and coauthors wrote.

Previous research has suggested that avoiding aggressive end-of-life care may lead to improved quality of life and lower healthcare costs. Although hospice use has increased overall during the past decade, many patients still receive intensive and invasive care in the last month of life, particularly minorities and/or patients of lower socioeconomic status.

Taylor, told OncLive that the study was not designed to explore why these disparities exist, but said it is clear that black and Hispanic women are not receiving optimal end-of-life care.

“The existence of these disparities is likely multifactorial. Additional education for patients and providers could be beneficial to start the conversation early regarding goals of care for the end of life,” she said. “An important initial step is starting the conversation early with all patients to discuss what patients understand about care near the end of life and what are their priorities and goals for care near the end of life.”

To identify racial and ethnic disparities in end-of-life care among patients with ovarian cancer, Taylor et al used Texas Cancer Registry-Medicare data to assess end-of-life care for women with ovarian cancer who died from 2000 to 2012.

The researchers evaluated a range of factors including:

• Chemotherapy in the final 14 days of life
• ICU admission in the final 30 days of life
• More than 1 ER or hospital admission in the final 30 days of life
• Invasive or life-extending procedures in the final 30 days of life
• Enrollment in hospice
• Enrollment in hospice during the final 3 days of life
• Enrollment in hospice while not hospitalized

A total of 3666 patients were included, 77% white, 15% Latina, 7% black, and 1% other. All patients had at least 13 months of continuous Medicare coverage before death. Most patients (72%) enrolled in hospice before death, but only 64% died while enrolled. Nearly 10% of patients who enrolled in hospice did so within the last 3 days of life.

Black (odds ratio [OR] = 0.74; 95% CI, 0.55-0.98; P = .04) and Latina (OR = 0.78; 95% CI, 0.62-0.97; P = .03) women were less likely than white women to enroll in hospice. Similarly, black (OR = 0.66; 95% CI, 0.50-0.88; P = .004) and Latina (OR = 0.76; 95% CI, 0.61-0.94; P = .01) women were less likely to die in hospice compared with white patients.

Among those who died after enrolling in hospice, patients of other or unknown race were more likely to enroll in hospice during the last 3 days of life (OR = 4.92; 95% CI, 2.09-11.60; P <.001).

No group was more likely than others to have multiple hospice enrollments before death. Researchers also found that demographics of patients who enrolled, but did not die, while in hospice were similar.

Latina (OR = 1.37; 95% CI, 1.05 to 1.78; P = .02) women and patients of other/unknown (OR = 2.42; 95% CI, 1.20-4.90; P = .01) were more likely to be admitted to the ICU in the final 30 days of life. In the final 30 days of life, black women were more likely to visit the ER more than once (OR = 2.20; 95% CI, 1.53-3.16; P <.001) and to receive a life-extending procedure (OR = 2.13; 95% CI, 1.50-3.04; P <.001).

The likelihood of having more than 1 hospital admission in the final 30 days of life and undergoing chemotherapy in the final 14 days of life did not differ by race.

A sensitivity analysis confirmed that black women had increased odds for dying while not enrolled in hospice and for visiting the ER more than once and receiving a life-extending procedure in the final 30 days of life. Latina women were more likely to be admitted to the ICU during the final 30 days of life.

Taylor JS, Rajan SS, Zhang, et al. End-of-life racial and ethnic disparities among patients with ovarian cancer. J Clin Oncol [published online April 7, 2017]. doi: 10.1200/JCO.2016.70.2894.