Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.
Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
J Pain Symptom Manage. 2018 Aug;56(2):185-194. doi: 10.1016/j.jpainsymman.2018.03.022. Epub 2018 Mar 30.
Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level.
This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making.
Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser.
About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120).
Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice.
越来越强调为晚期癌症患者尽早纳入姑息治疗，但在临床实践中实施仍存在障碍。已经制定了用于标准化转诊的标准，但尚未在人群层面上对其应用进行测试。
本研究通过检查癌症患者临终关怀的现有结局，以确定标准化转诊的必要性，并定义与预后不良相关的癌症病程中的过渡点，在此期间应常规引入姑息治疗以增强临床医生的决策。
这是一项在澳大利亚维多利亚州进行的基于人群的队列研究，纳入了 2000 年至 2010 年间诊断为非小细胞肺癌（NSCLC）、小细胞肺癌（SCLC）、前列腺癌或乳腺癌的晚期癌症住院患者，这些患者的信息来自常规收集的、相互关联的医院出院、急诊和死亡登记数据。描述性统计描述了死亡患者临终关怀结局的质量指标。采用 Kaplan-Meier 分析测试了最准确预测 6 个月或更短生存时间的预设过渡点。
大约 46700 例（56%为女性）患有转移性 NSCLC（n=14759；31.6%）、SCLC（n=2932；6%）、前列腺癌（n=9445；20.2%）和乳腺癌（n=19564；41.9%）。在 29680 名死者中，大多数（80%）死于医院，临终关怀结局不佳（83%），59%接受姑息治疗，中位数在死亡前 27 天。所有病例的癌症病程中的过渡点均确定为首次出现任何转移性疾病（NSCLC：3.8 个月[四分位距 {IQR}1.1，16.0]；n=14666；SCLC：4.2 个月[IQR1.0，10.6]；n=2914）；首次出现任何转移性疾病的多日入院（前列腺癌：6.0 个月[IQR1.3，26.4]；n=7174）；以及首次出现至少一个内脏转移部位的多日入院（乳腺癌：6.0 个月[IQR1.2，29.8]；n=7120）。
尽管姑息治疗的需求不断增加，但许多癌症患者接受姑息治疗的时间很晚或根本没有接受姑息治疗。我们的研究结果表明，应用有针对性的癌症特异性过渡点可以将姑息治疗作为癌症质量护理的标准组成部分进行整合，并在常规临床实践中增强临床医生的转诊。
