Advanced Cancer Population Has Low Use of Supportive Care at End of Life

A retrospective cohort study found that, of Medicare decedents with advanced cancer, 45% experienced potentially aggressive end-of-life care.

Even after significant efforts to improve the quality of end-of-life care, nearly half of patients with advanced cancer experience potentially aggressive care at end-of-life with low usage of supportive care, particularly among Medicare decedents with advanced cancer, a study published in JAMA Health Forum showed.¹

Within 6 months to the month of death, the mean number of acute care visits rose from 14.0 at month 6 to 46.2 at month of death for every 100 patient-months, hospice use rose from 6.6 to 73.5 for every 100 patient-months, palliative care rose from 2.6 to 26.1 for every 100 patient months, and advanced care planning increased from 1.7 to 12.8 for every 100 patient-months. The use of palliative care and advanced care planning was low overall, but both saw spikes in the month of death.

Including all decedents, a total of 45.0% experienced at least 1 indicator of potentially aggressive care. The highest rates of potentially aggressive end-of-life care were observed in non–small cell lung cancer (NSCLC; 47.7%), small cell lung cancer (SCLC; 47.1%), breast cancer (41.4%), pancreatic cancer (41.3%), and prostate cancer (37.6%).

The adjusted model showed that prostate and pancreatic cancer led to a −4.68 percentage point (95% CI, −7.17 to −2.19; P <.001) and −8.29 percentage point (95% CI, −10.06 to −6.52; P <.001) change, respectively, in the probability of receiving aggressive end-of-life care compared with those who had NSCLC. Patients who were older, non-Hispanic White, had a lower Yost Index of socioeconomic status quintile, and had a longer survival duration were less likely to receive any palliative care in adjusted analyses. Additionally, patients with NSCLC had a mean of 1.84 fewer days (95% CI, 0.25-3.43; P = .02) in hospice vs those with prostate cancer and a mean of 2.30 fewer days (95% CI, 1.17-3.43; P <.001) than those with pancreatic cancer.

“Even though clinicians and professional healthcare organizations have recommended early integration of supportive and palliative care for all patients with advanced cancers, it remains underused,” Robin Yabroff, PhD, MBA, scientific vice president of Health Services Research at American Cancer Society and lead investigator of the study, stated in a press release on these findings.² “High-quality patient-centered end-of-life care is especially important for maximizing remaining quality of life for this population, yet uptake of advanced care planning and palliative care was low and late hospice enrollment was common.”

A total of 33,755 Medicare decedents with advanced cancer 66 years or older who died of cancer were included in the retrospective cohort study; 2086 had breast cancer, 3239 had prostate cancer, 5595 had pancreatic cancer, 18,150 had NSCLC, and 4674 had SCLC. Eligible patients died of breast, prostate, pancreas, or lung cancer between 2014 and 2019.

Study analyses used data collected from Surveillance, Epidemiology, and End Results (SEER) and Medicare, which included approximately 26% of the US population.

The mean age of patients was 75.7 years, 52.1% were male, 80.5% were non-Hispanic White, 8.9% were non-Hispanic Black, 50.5% were married, 19.6% were dually enrolled in Medicaid, 69.4% were continuously enrolled in Part D, 54.6% lived less than 6 months, 44.4% had a score of 0 to 1 on the NCI comorbidities index, and 81.6% were from metropolitan areas.

Additionally, patients who were female, older, unmarried, or lived 6 months or longer after diagnosis were significantly less likely to receive potentially aggressive care. Conversely, patients who had greater comorbidity or were non-Hispanic Black were more likely to receive potentially aggressive care.

“To make meaningful improvements in the quality of [end-of-life] care, a multifaceted approach that addresses patient, physician, and system-level factors associated with persistent patterns of potentially aggressive care will be required,” the authors wrote in the study.¹

References

1. Kwon Y, Hu X, Shi KS, et al. Contemporary patterns of end-of-life care among Medicare beneficiaries with advanced cancer. Jama Health Forum. 2025;6(2):e245436. doi:10.1001/jamahealthforum.2024.5436
2. New ACS research finds low uptake of supportive care at the end-of-life for patients with advanced cancer. News release. American Cancer Society. February 21, 2025. Accessed February 26, 2025. https://tinyurl.com/fddev5d4