Eight years ago, a survey of the preferences of Dutch patients with cancer for health care found that while gender was one aspect influencing how men and women approach cancer care, it was the most important, with men, generally, regarding most care aspects as less important than women. The study concluded that to achieve optimal cancer care, physicians should tailor their communication, manner and extent of support, and consultation length, among other facets of care, based on a patient’s sex.¹

Fahad Saeed, MD

Now, a new study by Fahad Saeed, MD, and his colleagues, is showing that gender also influences patients’ preference for palliative care. In a cross-sectional analysis of data collected from 383 patients with advanced cancer enrolled in the Values and Options in Cancer Care (Voice) clinical trial, Dr. Saeed found that men with late-stage cancer were three times less likely than women to consider palliative care, even after covariates, such as disease aggressiveness, age, race, education level, and financial strain, were factored into the analysis.²

The study participants, aged 22 to 90 years, had stage III or IV nonhematologic cancer. At the beginning of the study, patients were asked about their preferences for palliative care, defined as “comfort care focusing on quality of life, but not a cure,” if their oncologist informed them that “there is no further anticancer treatment available that would be helpful.”

Gender preference for palliative care was not the only surprising finding from Dr. Saeed’s study. Additional analysis of the covariates found that older adults were less likely than younger adults to prefer palliative care. However, said Dr. Saeed, that result may be because most older patients, 68%, who were categorized as not favoring palliative care said they were “unsure” about the care, as opposed to “definitely” or “probably” against it, most likely because more than three-quarters of the respondents had never heard of palliative care.

Jamie H. Von Roenn, MD, FASCO

Previous research on patient attitudes about cancer treatment also shows gender differences in how men and women approach specific end-of-life care decisions, with men more likely to say they prefer life-sustaining interventions, such as cardiopulmonary resuscitation,³ and less likely to sign a do-not-resuscitate order.⁴

The ASCO Post talked with Dr. Saeed, Assistant Professor of Medicine in the Division of Nephrology and Palliative Care and Assistant Professor in the Department of Public Health Sciences at the University of Rochester Medical Center in Rochester, New York, about how more effective communication with male patients about the benefits of palliative care may help them choose less aggressive care at the end of life.

Discouraging the ‘Warrior’ Mode of Cancer

In your study, men were overwhelmingly—three times—less likely than women to consider palliative care over continued aggressive treatment for their advanced cancer. Were you surprised at such a large disparity in palliative care preference between men and women?

No, the results didn’t surprise me at all, because our findings are consistent with our clinical observations. Other studies have shown that men are far less likely to receive treatment for illnesses such as depression and are less likely to visit their doctor for routine checkups, so there are clues from other studies that men exhibit stoic behavior in the face of serious illness and are not comfortable expressing their emotions. Additionally, there is a societal norm that men are supposed to be tough and invulnerable and there is a lot of vulnerability in seeking help and focusing on comfort care instead of always being in fighter mode.

Men are out to “beat the cancer,” and some may perceive palliative care as giving up, even though studies show that early palliative care in the metastatic setting not only improves quality of life and mood, but can also lead to less aggressive care at the end of life and increase survival.⁵

I think this stoicism, toughness, lack of vulnerability, and a relative lack of emotional expression observed in many men may be playing a role in men being less likely to pursue palliative care.

Since there is a “war on cancer” and treatments are portrayed in the media as “fights” to win this war, these societal beliefs may push men, in particular, to fight their cancer rather than receive palliative care.

“Societal norms suggest that men are supposed to be tough and invulnerable, but there is a lot of vulnerability in seeking help and focusing on comfort care instead of always being in fighter mode.”

— Fahad Saeed, MD

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Distinguishing Between Palliative Care and Hospice Care

In your experience, do patients make the distinction between palliative care and hospice care?

I think understanding the difference between palliative care, which can be initiated at the time of diagnosis and throughout active treatment, and hospice care is difficult for patients. Palliative care focuses on enhancing patients’ quality of life while they are pursuing the most aggressive treatments, such as chemotherapy, but when a physician tells a patient that prognosis is limited, and that curative therapies are no longer an option, then the palliative care philosophy changes into hospice care, in which patients can still focus on their quality of life and also receive some extra comfort care support as an insurance benefit.

At entry to our study, patients were asked about their preferences for palliative care if their oncologist told them that “there is no further anticancer treatment available that would be helpful.” And to avoid any confusion, we defined palliative care as “comfort care focusing on quality of life, but not a cure,” but even in this scenario there was a large percentage of men who did not prefer palliative care.

Recognizing Patients’ Vulnerability

How can oncologists communicate more effectively with their male patients to help them more clearly understand the benefits of palliative care at every stage of survivorship, including end of life?

“Sometimes just giving patients permission to express their concerns openly and honestly in a safe environment is enough to make them feel comfortable about choosing less aggressive care at the end of life.”

— Fahad Saeed, MD

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The first step is for oncologists—and all physicians—to realize that gender differences in preference for palliative care exist and then to pay more attention to these differences, which can be subtle. Using distinct, gender-specific communication skills and techniques might be necessary to facilitate palliative care discussions. For example, explaining to their male patients that palliative care can benefit not just them but their family members as well by reducing the caregiving burden, which may increase patients’ receptivity toward palliative care. Physicians also need to acknowledge that having a terminal prognosis is difficult to accept and that all patients struggle with the reality of the situation and it is somewhat normal to feel depressed, angry, and anxious and that it is okay to express these emotions and to seek help to cope with these feelings as well as issues of physical pain.

The main message oncologists should convey is that patients’ feelings of vulnerability are normal and to assure patients that they will be with them throughout their illness and end of life and that palliative care doesn’t mean abandonment, but rather an extra layer of support to enhance their quality of life.

Sometimes just giving patients permission to express their concerns openly and honestly in a safe environment is enough to make them feel comfortable choosing less aggressive care at the end of life. We can all try to understand patients’ concerns when they are diagnosed with a life-threatening illness. After all, we are all human and we are all vulnerable. ■

DISCLOSURE: Dr. Saeed reported no conflicts of interest.

REFERENCES

1. Wessels H, de Graeff A, Wynia K, et al: Gender-related needs and preferences in cancer care indicate the need for an individualized approach to cancer Patients. Oncologist 15:648-655, 2010.

2. Saeed F, Hoerger M, Norton SA, et al: Preference for palliative care in cancer patients: Are men and women alike? J Pain Symptom Manage 56:1-6.e1, 2018.

3. Phillips RS, Wenger NS, Teno J. et al: Choices of seriously ill patients about cardiopulmonary resuscitation: Correlates and outcomes. SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med 100:128-137, 1996.

4. Sharma RK, Prigerson HG, Penedo FJ, et al: Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death. Cancer 121:2814-2820, 2015.

5. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 363:733-742, 2010.