End-of-Life Care in Multiple Myeloma Still Requires Fine-tuning, Despite Improvements

Thirteen years of population-based data highlight substantial rates of aggressive end-of-life care and disparities in care within a publicly funded health care system in Ontario, Canada.

Although outcomes for patients with multiple myeloma (MM) have improved in recent years due to advances in treatment, there is a need to optimize end-of-life (EOL) care in this patient population, according to a recent population-based analysis in Ontario, Canada.

MM is a hematological cancer associated with significant morbidity and mortality, and patients typically face a high symptom burden throughout the disease. Palliative care has known benefits for patients with MM, including lesser symptom burden and better reported patient and caregiver experiences. Therefore, international guidelines recommend palliative care early in the course of cancers such as MM and parallel to active treatment. However, past research shows that palliative care is still underutilized in MM and that hospitalization and aggressive treatment rates at EOL are high in this patient population.

The study, published in British Journal of Haematology, assessed EOL care quality for patients in Ontario over a 13-year period using data from the Ontario Cancer Registry. The main objective was to analyze EOL care patterns and trends over time, as well as assess any disparities in the publicly funded health system.

The analysis included data from patients 18 years or older who died as a result of MM between January 1, 2006, and December 31, 2018. A total of 5095 patients were included in the study. Of those patients, 1398 (27.4%) received autologous stem cell transplantation (ASCT), while the remaining 3697 patients (72.6%) did not receive ASCT. The median age at death was 74 years in the overall cohort, 63 years in the ASCT cohort, and 78 years in the non-ASCT cohort. Median time from diagnosis to death was 3.6 years overall, 5.3 years for patients who received ASCT, and 3 years for patients who did not receive ASCT.

Overall, 28.3% of the ASCT cohort and 20.4% of the non-ASCT cohort received aggressive EOL care, defined as 2 or more emergency department visits in the 30 days before death or admission to the intensive care unit within 30 days before death. A total of 65.4% of the ASCT cohort and 61.5% of the non-ASCT cohort received supportive care at EOL, defined as a physician house-call within 2 weeks before death or an at-home palliative nursing or personal support visit within 30 days before death. The majority of patients received any palliative care service in the last 6 months of life (86.9% of the ASCT cohort and 84.9% of the non-ASCT cohort).

In the overall cohort, 23.2% of patients received chemotherapy during the last 2 weeks of life and 55.6% of patients died while hospitalized. In the ASCT cohort, 73.4% of patients were hospitalized in the last 30 days of life, and in the non-ASCT cohort, 61.4%.

Inpatient deaths decreased from 60.7% in 2006 to 47.8% in 2018, and new hospitalizations within 30 days of death decreased from 68.6% to 60%, respectively. More patients received home supportive care at EOL over time (56% in 2006 vs 70.3% in 2018), while the rates of aggressive care receipt within 30 days of death stayed similar over time (22.5% in 2006 vs 20.6% in 2018). The use of any palliative care within the last month of life increased from 57.3% in 2006 to 90.4% in 2018.

Supportive care was less utilized in patients 80 years or older compared with patients aged 60 to 69 years (adjusted odds ratio [aOR], 0.72; 95% CI, 0.59-0.88), but more commonly utilized in patients aged 18 to 49 years vs patients aged 60 to 69 years (aOR, 1.91; 95% CI, 1.2-3.06). Patients in lower-income neighborhoods were also less likely to receive supportive care compared with patients in the highest income quintiles (aOR, 0.65; 95% CI, 0.53-0.78).

Patients 80 years and older were less likely to receive aggressive EOL care compared with patients aged 60 to 69 years (aOR, 0.54; 95% CI, 0.42-0.68), and residents of smaller rural communities of less than 10,000 were more likely to receive aggressive care vs those in communities of 1.5 million or more residents (aOR, 1.89; 95% CI, 1.51-2.36). Women were less likely to receive aggressive care than men, but as likely as men to receive supportive care.

Overall, patients who died within 180 of receiving their MM diagnosis were less likely to receive palliative care within 30 days of death compared with those who lived for 3 to 6 years after diagnosis (OR, 0.67; 95% CI, 0.51-0.89).

The study was the first to evaluate EOL care for MM among a population-based cohort in a publicly funded health care system, and the findings highlight disparities in care based on age, income, and community size that need to be addressed. In addition, despite improvements over time, a relatively large proportion of patients with MM continue to receive aggressive care at EOL, and many are hospitalized. The findings are in line with those of other studies done in the same area.

Future research should include qualitative studies and prospective trials to determine the best palliative care approach for patients with MM, including the best time frames for palliative care use, the authors concluded.

Reference

Mohyuddin GR, Sinnarajah A, Gayowsky A, Chan KKW, Seow H, Mian H. Quality of end-of-life care in multiple myeloma: A 13-year analysis of a population-based cohort in Ontario, Canada. Br J Haematol. Published online August 10, 2022. doi:10.1111/bjh.18401

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