Better end of life care for prostate cancer patients

Is there a better way to die when you have prostate cancer? Health economist Alice Dragomir and her team delved into this question in their study supported by the Rossy Cancer Network’s Cancer Quality and Innovation (CQI) Fund.

"In general, people believe it's better to die from something other than cancer, so we wanted to compare and see if quality of life really is better for people who die from other causes," explains Ms. Dragomir, Assistant Professor in the Department of Surgery, Division of Urology at McGill University. The objective of the study is to assess the survival and quality of life of patients who die from prostate cancer compared to those who die from other causes by phase of the disease, including an evaluation of the intensity of healthcare utilization in the end of life period.

Typically, prostate cancer progresses slowly and patients are more likely to die from other diseases, especially cardiovascular disease, stroke or other more aggressive cancers. On the other hand, prostate cancer patients often face a number of side effects that lead to medical interventions that can impact their quality of life as they near death. These include metastases to the bone, which can cause painful bone lesions, as well as bladder and bowel issues, all of which are regularly treated surgically or medically to relieve symptoms. "We see that patients with prostate cancer are very aggressively treated until their end of life," says Ms. Dragomir.

“This kind of research is really forward thinking and puts objective measures around a very sensitive topic – patients’ end of life care,” explains Dr. Ari Meguerditchian, the program lead for the RCN’s Cancer Quality & Innovation program. “This study will help institutions evaluate how they can better reallocate the finite resources of the healthcare system to make the biggest difference for patients and provide high-value care.”

Examining the current state

Using Quebec's RAMQ database, Ms. Dragomir and her team from the McGill University Health Centre and the Jewish General Hospital, are analysing quality of life indicators for patients diagnosed with prostate cancer in the last year of their life. These indicators include emergency department visits, hospitalizations (including ICU admissions) and chemotherapy use in last 30 days of life; healthcare resource use and their associated costs in the last six months of life; as well as outpatient visits, drug treatments, and other medical interventions.

Eight thousand patients who died from prostate cancer in Quebec between 2007 and 2016 were matched with a control group of 8,000 patients diagnosed with prostate cancer but who died from other causes (cancers, cardiovascular disease or other) during the same period.

Introducing palliative care earlier

The team has completed the analysis of the group of patients who died from prostate cancer and released preliminary results last year. Chemotherapy use and ICU admissions were low for this group, but other healthcare utilization remained high as these patients near death, particularly hospitalizations, emergency department visits, and the use of androgen deprivation therapy (ADT).

"We found that the patients dying of prostate cancer will stay on the ADT drug abiraterone until their last month of life which is in fact a little bit questionable. This should probably be done differently with less intensive treatment and more palliative treatment, because this is aggressive care," explains Ms. Dragomir. "We observed that for these patients, the benefits of these treatments are close to zero and the healthcare system cost is high. There are healthcare expenditures that could be reduced if we had a more optimal usage of these resources."

The team is now looking at results for prostate cancer patients who died from other causes. Dr. Dragomir says she and her team hope that the final results, which should be ready by the end of the year, will help them identify gaps in quality of healthcare services at the end-of-life in men dying of prostate cancer.

"Knowing which services patients receive before dying is useful in assessing if they are actually using resources that lead to better quality of life before death, and this could lead to solutions in improving areas for improvement," says Dr. Dragomir.

“We want to prevent prostate cancer patients from having to cope with aggressive treatment, significant side effects and time spent in hospital when they would rather be at home with their families,” states Dr. Wilson Miller, the RCN’s clinical lead. “The RCN is committed to making end of life care a target of improvement; we want to promote dignity in the last stage of a cancer patient’s life.”


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