P4-13-02: Hospice Utilization and End of Life Care in Metastatic Breast Cancer Patients at a Comprehensive Cancer Center.
Authors: O'Connor TL , Ngamphaiboon N , Morris J , Callinan NK , Milch RA , Kerr CH , Watroba N , Edge SB 
Published: June 2012

Abstract
Background: Metastatic breast cancer patients have many options for therapy and may be at risk for late or absent hospice referrals. Previous studies suggest that late referrals to palliative care make meaningful improvements in symptoms and quality of life difficult to achieve. We examined hospice utilization, status of patients on hospice admission, and quality of care documentation in patients treated for metastatic breast cancer at Roswell Park Cancer Institute (RPCI) from 1999–2010.
Methods: Analysis of breast cancer cases through the RPCI database identified 182 cases with deaths resulting from breast cancer eligible for services through The Buffalo Center for Hospice and Palliative Care (HB) (residence in Erie County, NY). Cases were cross-matched to the HB database for information on hospice utilization and outcome, and patient symptoms/status on admission to hospice. Date of last chemotherapy, opiate use, anxiolytic use, documentation of advance directive and palliative care discussion, and place of death were collected through chart abstraction.
Results: 182 patients eligible for HB services expired from breast cancer during the study period. 122 (67%) utilized hospice services; 60(33%) did not. 117 patients received chemotherapy as their last treatment for metastatic breast cancer; patients referred to hospice received their last dose of chemotherapy a median of 31 days (14.1−47.9) prior to death; non-hospice patients 16 days (0-44.1) p=0.071. Patients subsequently admitted to hospice were significantly more likely to have a discussion of advance directives by their oncology team (30% vs. 5% p=&lt;0.001) and were more likely to die at home (56% vs. 8%, p=&lt;0.001). Only 7% of the 60 patients who died without a hospice referral had a documented discussion of palliative care as a therapeutic option by the oncology team (p&lt;0.001) versus 100% of patients referred to hospice. 79% of breast cancer patients not admitted to hospice died in an acute care setting. Prior to hospice admission or death, 38% (69) patients had documentation of long-acting opiate use; 72% (131) were prescribed a short acting opiate, while 29% (52) patients were prescribed an anxiolytic. Median length of stay (LOS) was 17 days; 14% of patients died within 3 days of admission. Patient status on hospice admission is reported in Table 1.

Conclusion: Despite the recognition of the importance of high-quality end of life care, including end of life decision-making, advance directives, pain and symptom management, and hospice care, 33% of metastatic breast cancer patients at our institution died without hospice referral. Those patients referred to HB were significantly more likely to have an advance directive discussion, and to die at home. However, patients referred to HB had a median LOS of 17 days, and poor PPS. Efforts to enhance discussion of palliative care earlier in the treatment of MBC are critical to improved patient care.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-13-02.