Utilisation of Hospital-Based Specialist Palliative Care in Patients With Gynaecological Cancer: Temporal Trends, Predictors and Association With High-Intensity End-of-Life Care

Abstract

ABSTRACT Although chemotherapy and short-course radiotherapy play important roles in the palliative management of gynecological cancers, these may be associated with significant discomfort and minimal symptom control in advanced disease. Terminally ill patients approaching death may have complex palliative care needs that cannot be resolved in general care practices and require multidisciplinary specialist palliative care services (SPC). Timely access to SPCs is associated with improved quality of life and reduced high-intensity care during the end-of-life phase; however, the role of palliative care on high-intensity interventions at the end of life in patients with gynecological cancers has not been examined in large-scale studies. This nationwide registry-based study aimed to examine the temporal trends, predictors of use, and relationship with high-intensity treatments in hospital-based SPC utilization among patients with gynecological malignancies. All adults in Denmark who died of gynecological cancer between 2010 and 2016 were included. Demographic, financial, and oncological data were obtained for each patient. Utilization of SPC included care provided during hospital admissions, in outpatient clinics, or in the patients' own home. High-intensity end of life care included invasive treatments (chemotherapy, surgery, and radiation), use of services such as emergency department visits, intensive care unit admissions, or more than 1 hospital admission within 30 days, as well as no hospice admissions in the prior year or a patient death in the hospital. Binary regression was used to estimate the chance of receiving hospital-based SPC and the adjusted relative risk of high-intensity end of life care by potential predictors including cancer type, age at death, comorbidity score, region of residence, marital status, income level, migrant status, and FIGO cancer stage. A total of 4502 patients with cervical cancer (n = 708), ovarian cancer (n = 2595), and endometrial cancer (n = 1199) were identified, of whom 179 (40.0%) accessed SPC. The proportion of patients dying of gynecological cancer and receiving SPC increased from 24.2% in 2010 to 50.7% in 2016. Each potential predictor studied was associated with receiving SPC at the end of life, with the strongest associations after adjustment for year of death between 2014 and 2016, younger age, 3 or more comorbidities, residence in Danish regions other than the Capital region, and being an immigrant or descendant. Patients aged 60 to 69 had a 24% decreased chance of receiving SPC compared with those aged 18 to 59 (adjusted relative risk [aRR], 0.76; 95% confidence interval [CI], 0.69–0.83), and as age increased, the proportion of those that received SPC decreased further. Those with 3 or more comorbidities had a 23% higher chance of receiving SPC (aRR 1.23; 95% CI, 1.13–1.34). Compared with nonimmigrants, immigrants and descendants were 29% more likely to receive SPC (aRR, 1.29; 95% CI, 1.14–1.96). Hospital-based SPC, particularly when accessed >30 days before death, was associated with lower utilization of all high-intensity end of life care including a 25% lower risk of dying during a hospital admission (aRR, 0.75; 95% CI, 0.68–0.84). The results of this study demonstrate that the proportion of patients dying of gynecological cancers and receiving hospital-based SPC increased significantly between 2010 and 2016, and these patients received fewer high-intensity end of life interventions and were less likely to die during a hospital admission.