Alexandra S. Bercow, MD, discusses the implications of research showing that patients with advanced-stage cervical cancer who received palliative care consultations underwent the same level of treatment but had shorter, less acute, and fewer hospital stays than their counterparts who were not given such referrals.
Alexandra S. Bercow, MD
Patients with advanced-stage cervical cancer who received palliative care consultations underwent the same level of treatment but had shorter, less acute, and fewer hospital stays than their counterparts who were not given such referrals, according to retrospective study findings.
A window into the impact of palliative care for this patient population emerged from results of a study involving 153 patients who died of cervical cancer after being diagnosed with the disease from January 2000 through mid-February 2017 and undergoing treatment at Massachusetts General Hospital or Brigham and Women's Hospital, both in Boston.
A palliative care consultation was significantly associated with a referral to hospice care (P <.001) and death in hospice (P <.001) but fewer measures of aggressive care, according to Alexandra S. Bercow, MD, who presented the findings during the 2020 Society of Gynecologic Oncology Winter Meeting.
In an interview, with OncLive®, Bercow, a clinical fellow in obstetrics, gynecology, and reproductive biology at the 2 institutions, discussed the implications of this research.
OncLive: How do outcomes differ by stage in cervical cancer?
Bercow: The prognosis for patients with cervical cancer varies widely across cervical cancer stages. Patients with stage I have very good prognoses, and oftentimes, they are cured with no recurrence. However, patients diagnosed with advanced disease, such as stage III or IV, carry a 5-year survival rate of only 17%.
What are the challenges of treating patients with advanced disease?
The mainstay of treatment for advanced cervical cancer is chemoradiation. Unfortunately, chemoradiation carries high morbidity. It often leads to a high symptom profile and a low quality of life. There are different immunotherapies that may be improving the recurrence rate and remission rate for patients with advanced-stage cervical cancer. There are also many new drugs that people are looking at, such as the immune checkpoint inhibitors.
What was the rationale for evaluating palliative care in this population?
There have been many studies on palliative care within gynecologic malignancies, but there haven’t been robust studies looking at palliative care specifically for patients with cervical cancer. Often, it is either just looked at in ovarian cancer or endometrial cancer or gynecologic malignancies in general with a very low proportion of patients with cervical cancer.
In addition, patients with cervical cancer carry a vastly different profile than both ovarian and endometrial cancers. These patients are younger, often from a minority background, have a lower socioeconomic status, lower healthcare literacy, and therefore, have poorer access to healthcare. We hypothesized their uptake in palliative care may be different from their ovarian and endometrial counterparts, given their vastly different end-of-life needs.
How did you study this question?
We did a retrospective study, which examined patients who died from cervical cancer at our 2 institutions between 2000 and 2017. We looked through their charts to figure out whether they had been referred to palliative care and then what type of palliative care consultation they had—inpatient versus outpatient.
What were the findings from this study?
We found several things. The first is that in our 2 groups, patients who did receive a palliative care consult and those who did not were slightly different in age. The women who were referred to palliative care were significantly younger with a median age of 49 compared with 57.5. There was a 47% palliative care referral rate, which is low when you think about the fact that all of these women had died from the disease and likely would have needed palliative care the most.
We also learned there were more inpatient consultations than outpatient consultations. We found palliative care was significantly associated with a hospice referral and death in hospice. In addition, we discovered that patients who had a palliative care consult spent more time in hospice—21 days—than those who did not have a palliative care consult—12 days.
Finally, we looked at measures of aggressive care that are recommended by the National Quality Forum. We found that palliative care consults were associated with the following: fewer ICU [intensive care unit] admissions; fewer emergency department visits; shorter and less frequent hospitalizations; a decreased death rate in the acute care setting; a decrease in the death rate on the inpatient floor, the ICU, or the emergency department; as well as an increased rate of co-discussion with the primary providers within the patient’s last 30 days of life.
We also found that the 2 groups received the same amount of treatment at the end of life, the same amount of chemotherapy and radiation for the last 30 days of life, and the same amount of invasive procedures in the last 3 months of life. Importantly, that did not lead to increased time spent in the hospital. The patients still spent less time in the hospital, which we think is valuable to quality of life and overall end-of-life care.
What is the take-home message?
Of course, it is important to think about the individual patient. Studies have shown time and time again that the earlier we can integrate palliative care into our conversations with our patients and into our treatment, the less resistant they will be, but it may also [improve] their symptom control. As gynecologic oncologists, we have very limited time to spend with our patients, unfortunately, between operating on them, giving them chemotherapy, and having follow-up visits. We might not always have time to treat every single one of their symptoms as well as we would like to. Incorporating palliative care would create a multidisciplinary picture that allows us to care for our patients more as a whole.