Men dying of prostate cancer referred too late

More than half of men dying of prostate cancer use hospice care, which is a significant increase over the last two decades; however, most wait too long to enroll so they can't take full advantage of the palliative care that could make their deaths easier, a study by researchers at UCLA's Jonsson Comprehensive Cancer Center found.

The study also found that men with spouses or partners were more likely to take advantage of hospice care, while African American men were 20% less likely to enroll.

For hospice care to be most effective, patients should be enrolled for several weeks prior to their deaths. However, the study found most men enrolled just one to two weeks before they died, said Mark Litwin, MD, a professor of urology and public health, a Jonsson Cancer Center researcher, and senior author of the study.

"It's important that we maximize quality of life when quantity of life cannot be changed," Litwin said. "Most men are being referred to hospice too late, and that timing hasn't changed in the last 20 years, which is unfortunate. As cancer specialists, we should offer these patients the best quality of life that we can, and that often means offering them the best quality of death that we can give them."

The primary reason for the delay in referrals to hospice is that oncologists often are loathe to give up the fight, and they aren't good at predicting how long patients have left to live. Additionally, medical students aren't taught that preservation of life may not be the sole goal in caring for patients.

"As doctors, we often don't want to give up. We've sworn to help our patients, and a death is a failure to us," Litwin said. "But the optimization of life should be our goal. Sometimes survival is of such poor quality that it should not be our primary goal."

Programs have been launched at the David Geffen School of Medicine at UCLA to address the importance of quality of life and palliative care, Litwin said. However, it can take a time to make a significant change in the institutional mentality.

Patients are not referred to hospice care early enough, agrees David Wallenstein, MD, a clinical assistant professor of family medicine who works with the UCLA Palliative Care Service and serves as medical director for the Skirball Hospice at the Jewish Home of Los Angeles. He has seen patients referred to hospice who die the same day they arrive.

'"What would be ideal when a patient is referred for hospice care is that we have enough time to control their pain and symptoms and enhance their quality of life," Wallenstein said. 'It's difficult to pinpoint exactly how much time is enough, but Wallenstein said "it would be nice to have at least a couple of weeks."

"If you have more time, you can fine tune the medications, try a variety of medications, and work to minimize side effects," he said. "You can control pain pretty easily, but is the patient going to be awake and alert? Most patients prefer to be interactive with their loved ones when the end is near."

Litwin's study also found that utilizing hospice care could decrease healthcare costs, as those patients were not prescribed costly, but ultimately futile, therapies. "In an era when increased attention is being focused on what to do to reign in runaway healthcare costs, there should be a clear focus on limiting therapies that ultimately will fail for these patients: costly chemotherapy treatments, more imaging studies, emergency room visits, lengthy ICU stays," Litwin said. "We need to eliminate costs that don't provide benefit and try to give our patients the most dignified deaths that we can."

For most prostate cancer patients, the arc from diagnosis to death is a long and often slow one, and men most often die from other causes before their prostate cancer can kill them. But there are about 30,000 men every year who will die from their disease, and providing appropriate palliative care to this population is vital, Litwin said.

"Studies have shown that the quality of the death experience is much greater when everyone has the opportunity to face the issues and say the things they need to say," he said. "Looking back, family members who use hospice rate the quality of the death experience much higher than those who did not use hospice."

For the study, Litwin and his team identified 14,521 men aged 66 and older who died of prostate cancer between 1992 and 2005. Searching in-patient and physician claims, the team was able to identify those patients that enrolled in hospice care. Of the 14,521 studied, 7,646 or 53% used hospice care for a median of 24 days. About 22% of patients in the study enrolled within seven days of their death.

"Hospice stays shorter than seven days are too brief to maximize the benefit of enrollment, and individuals making shorter stays receive fewer services and benefit less from the input of the full interdisciplinary team," the study states. "Increasing appropriate hospice use may improve the quality of death for men at the end of life while rationalizing health care expenditures during this high-cost period."

The study was funded by the Urologic Diseases in America Project, which is sponsored by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases, a part of the National Institutes of Health.