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

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A study to examine 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,” Firas Abdollah, MD, of the Henry Ford Health System, Detroit, and colleagues reported in the Journal of the National Comprehensive Cancer Center.

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 admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life,” the authors explained.

Racial Differences

Overall, the 729 black patients (19.24%) were less likely than the 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), prostate-specific antigen 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%), radiotherapy (32.7% vs 40.0%), and to have office visits (81.6% vs 92.7%). The P value ≤ .005 applies to all diagnostic and therapeutic interventions.

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 intensive care unit admission, inpatient admission, and cardiopulmonary resuscitation all were more frequent among black men than white men (all P ≤ .003).

On multivariate analyses adjusting for covariates, 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.

‘Noteworthy Findings’

The authors asserted that their study “has several noteworthy findings.” They include highlighting “the stark contrast in end-of-life care among black patients compared with white patients.” Aggressive treatments such as intensive care unit 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 remarked.

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.” ■

Abdollah F, et al: J Natl Compr Canc Netw 13:1131-1138, 2015.