Aggressive End-of-Life Care More Frequent Among Black Than White Men With End-Stage Prostate Cancer

Key Points

  • Black men with end-stage prostate cancer are less likely to have diagnostic and therapeutic interventions and more likely to have aggressive end-of-life care than white men in the last 12 months before death.
  • Aggressive treatments close to death may represent poor quality of care, because these treatments have a significant adverse psychological, physical, and monetary impact on patients and their caregivers.
  • Ensuring adequate primary health care and outpatient visits can possibly help improve the quality of end-of-life care.

A study to examine racial disparities in end-of-life care among black and white patients dying of prostate cancer found that “significant racial disparities in end-of-life care" do exist. “Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage [prostate cancer], the rate of high-intensity and aggressive [end-of-life] care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage [prostate cancer],” Abdollah et al reported in the the Journal of the National Comprehensive Cancer Network.

Researchers relied on data from the Surveillance, Epidemiology, and End Results (SEER) registries linked to the Medicare database to identify 3,789 patients who died of metastatic prostate cancer between 1999 and 2009. Exclusion criteria included race other than black or white. Black men were slightly younger at death, with a median age of 76.6 years vs 79.3 years for white men.

“Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life,” the authors explained.

Fewer Tests and Therapeutic Interventions

Overall, the 729 black patients (19.24%) were less likely than white patients to have diagnostic tests in the 12 months preceding death. They included laboratory tests (89.2% for black patients vs 94.8% for white patients), PSA tests (68.3% vs 82.4%), cystourethroscopy (16.5% vs 21.2%), Foley catheter placement (12.2% vs 16.4%), and imaging procedures (90.0% vs 93.9%). Black patients were also less likely to receive hormonal therapy (50.9% vs 66.8%), chemotherapy (30.6% vs 44.3%), and radiotherapy (32.7% vs 40.0%), and to have office visits (81.6% vs 92.7%), with P ≤ .005 for all these comparisons.

Conversely, in the 12 months before death, high-intensity end-of-life care was more frequent in black patients, 93.5% vs 90.2% for white patients, P = .004). More than one emergency department visit, an ICU admission, inpatient admission, and cardiopulmonary resuscitation were all more frequent among black men vs white men (all P ≤ .003).

These observations for diagnostic and therapeutic interventions and for high-intensity end-of-life care were similar at 3 months and 1 month before death on multivariate analyses adjusting for covariates.

Several ‘Noteworthy Findings’

The authors assert that their study “has several noteworthy findings.” These include highlighting “the stark contrast in [end-of-life] care among black patients compared with white patients.” Aggressive treatments such as ICU and inpatient admissions “close to death may represent poor quality of care, because these treatments have a significant adverse psychological, physical, and monetary impact on both the patients and their caregivers,” the authors noted.

Although encouraged that “the proportion of black and white patients receiving high-intensity [end-of-life] care has significantly decreased over the past 10 years,” the investigators noted that “a greater proportion of terminally ill black patients continue to receive high-intensity [end-of-life] care relative to their white counterparts.” Possible explanations offered for this disparity include “resistance to use of palliative care and hospice care among black patients, driven by patient and family preferences, a lack of proper physician-patient communication, or the lack of awareness about [end-of-life]options and outcomes.”

Another “noteworthy finding” concerned the significantly lower proportion of black patients who had office visits compared with white patients. “This finding may reflect lesser availability and access to primary health care facilities in black patients, which has been evaluated by several previous studies,” the investigators stated. “Ensuring adequate primary health care and outpatient visits can possibly help in improving quality of [end-of-life] care in these patients.”

Firas Abdollah, MD, of the Henry Ford Health System, Detroit, is the corresponding author for the Journal of the National Comprehensive Cancer Network article.

For full disclosures of the study authors, visit www.jnccn.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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