The association of demographic factors and disease stage on palliative care (PC) referral rates and completion of advanced directives in a lung cancer (LC) patient population.
Authors: Karkash Ahmad , Ajrouch Ali , Rangoonwala Hussain I , Hanna Nasser H. , Aljaras Razan , Khalifeh Yara , Hajj Ali Adel , Menakuru Sasmith , Jalal Shadia Ibrahim 
Published: June 2023

e24150

Background: Early referral to PC improves quality of life among patients with lung cancer and is associated with improvement in overall survival in patients with stage 4 disease. However, PC utilization remains low. Few studies examined the disparities in PC access and use in real life SCLC and NSCLC patient populations. Objective: To determine the prevalence of PC use among a sample of LC patients and assess the role of PC in facilitating directives and goals of care discussion. Methods: A retrospective cohort analysis was conducted utilizing a randomly selected subset of LC patients treated at the IU Simon Comprehensive Cancer Center between 1/1/18 and 12/31/20. We collected information on advanced directives in the form of designated medical decision maker (Healthcare representative or Healthcare power of attorney) and code status preferences (DNR or POST form). Signed DNR order/POST forms information, demographics (sex, race), LC stage, and LC type were analyzed using descriptive analyses. Chart search identified the dates of first palliative care visit and number of total palliative care visits. Results: Patient characteristics (n = 209): Females 51.7%; White 86.7%; NSCLC 88.5%; stage IV 44.1%. The percentage of total patients who were referred to palliative care was 21.1%. No significant difference in referral rates was found between NSCLC and SCLC patients. 22.3% of male patients and 19.8% of female patients were referred to PC (p = 0.61). No difference was noted in the percentage of white and non-white patients referred to PC (21% and 26.1%, p = 0.97). Palliative referral rates and time from diagnosis to first palliative contact was significantly associated with disease stage, as 27.9% of patients with stage 4 were referred to palliative compared to 15.6% of patients with stages 1-3 (p = 0.036); median time from diagnosis to first palliative contact in stage 4 patients was 355.7 days vs 573.7 days in stages 1-3. Disease stage was associated with the median time from diagnosis to signing POST/DNR forms: 213.6 days in stage 4 patients vs. 409.1 days in stage 1-3 patients. Discussing and signing POST/DNR and HCPOA/HCR forms was associated with palliative care referrals; 53.7% and 63.6% of those referred to palliative signed POST/DNR and HCPOA/HCR forms respectively vs. 11.4% and 16.9% for patients who were never referred to PC. Conclusions: Stage 4 LC was associated with higher likelihood of referral to palliative care than stages 1-3 but PC was underutilized in LC. Demographic factors (race, sex) were not significantly associated with PC referral rates. Patients referred to PC were more likely to address advanced directives than patients who were never offered PC. Strategies to increase palliative care utilization and barriers limiting PC utilization in LC patients need to be further investigated.