Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan

Abstract

Mahmoud Abunasser,1– 3 Hala Abu-Fares,1 Sarah Abdel-Razeq,2 Omar Shamieh,2,3 Osama Salama,1 Khaled Ashouri,1 Abdullah Al Qudah,1 Ayat Taqash,4 Hala Abu-Jaish,5 Salwa S Saadah,1,2 Hikmat Abdel-Razeq1,2 1Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan; 2School of Medicine, the University of Jordan, Amman, Jordan; 3Department of Palliative Medicine, King Hussein Cancer Center, Amman, Jordan; 4Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan; 5School of Medicine, Jordan University of Science and Technology, Irbid, JordanCorrespondence: Hikmat Abdel-Razeq, Department of Internal Medicine, King Hussein Cancer Center, 202 Queen Rania Al Abdullah Street, P.O. Box: 1269, Amman, 11941, Jordan, Tel [phone], Ext: 1000, Email [email protected]: Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.Methods: All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.Results: During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥ 30 days prior to death), 182 (42.0%) had late referral (< 30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20– 2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38– 3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48– 6.38, p = 0.0027). Fewer patients in the “no referral” group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).Conclusion: Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.Keywords: metastatic breast cancer, palliative care, end-of-life, Do not resuscitate, DNR

Keywords

• metastatic breast cancer
• palliative care
• end-of-life
• don't resuscitate
• dnr