Abstract P5-08-03: Predictors of aggressive end-of-life care in women metastatic breast cancer
Authors: Accordino MK , Wright JD , Vasan S , Neugut AI , Hillyer GC , Hershman DL 
Published: March 2017

Abstract
Background: Despite recommendations against aggressive end-of-life (EOL) care, a high percentage of patients with metastatic breast cancer (MBC) receive aggressive EOL care. MBC is a heterogeneous disease with a wide variation in survival. EOL care may differ by the patients' long-term course of care. We performed a population-based analysis to evaluate patterns and predictors of aggressive EOL care and associated costs among women with MBC.
Methods: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify female patients with MBC diagnosed between 2002 and 2011. Aggressive EOL care in the last month of life was identified using claims data. Specifically: ≥2 emergency department (ED) visits, ≥2 hospital admissions, &gt;14 days hospitalized, admission to the intensive care unit (ICU), admission to hospice within 3 days or less before death, and receipt of intravenous (IV) chemotherapy in the last 14 days of life were evaluated. Direct healthcare costs in the last month of life were calculated from Medicare claims. Patients were categorized into prognosis quartiles based on survival time from diagnosis. Multivariable analysis was performed to identify patient characteristics associated with aggressive EOL care and characteristics associated with high direct healthcare expenditures in last month of life in women with hormone-receptor (HR)+ and HR- MBC. High expenditures were defined as median costs &gt;75th percentile. Factors associated with high expenditures were evaluated using linear regression.
Results: We identified 5,064 eligible patients. Of these, 2,156 (42.6%) received at least one measure of aggressive EOL care in the last month of life. The most frequent aggressive EOL care received in the last month of life were ICU admissions (17.3%) and &gt;1 ED visits (14.1%). Median cost of care in the last month of life was $7,973. Predictors of aggressive EOL care included year of diagnosis (OR 1.04, 95% CI 1.02-1.06), black race as compared to whites (OR 1.50, 95% CI 1.25-1.79), being married compared to single (OR 1.15, 95% CI 1.01-1.32), and a Charlson comorbidity score of ≥2 compared to no comorbidities (OR 1.52, 95%CI 1.32-1.75). Predictors of not receiving aggressive EOL care included age &gt;74 compared to ages 70-74, receiving care in the Midwest compared to the East (OR 0.82, 95% CI 0.70-0.96), and best prognosis compared to worst prognosis (OR 0.46, 95% CI 0.39-0.55). Predictors of high last month of life expenditures were similar in both the HR+ and HR- subsets; receipt of more aggressive EOL care was also associated with higher expenditures in both HR subsets (OR 5.02, 95% CI 3.88-6.49; OR 5.43, 95% CI 3.41-8.65, respectively). Median last month of life expenditures were unchanged from 2002-2012 for the whole population ($7,658 to $5,910, p=0.93), but rose significantly in patients in the worst prognosis quartile ($9,236 to $16,926, p&lt;0.0001)
Conclusion: Patients with MBC frequently received aggressive EOL care. Women with poor prognosis were more likely to receive aggressive EOL care and have higher expenditures in the last month of life. Given the rising costs of cancer care, efforts should be made to identify patients early for EOL interventions to reduce costs, particularly in women with a poor prognosis.
Citation Format: Accordino MK, Wright JD, Vasan S, Neugut AI, Hillyer GC, Hershman DL. Predictors of aggressive end-of-life care in women metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-03.