Harvard Medical School, Boston, MA 02115, USA.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
J Natl Cancer Inst. 2020 Dec 14;112(12):1251-1258. doi: 10.1093/jnci/djaa036.
Brain metastases are associated with considerable morbidity and mortality. Integration of hospice at the end of life offers patients symptom relief and improves quality of life, particularly for elderly patients who are less able to tolerate brain-directed therapy. Population-level investigations of hospice utilization among elderly patients with brain metastases are limited.
Using the Surveillance, Epidemiology and End Results-Medicare database for primary cancer sites that commonly metastasize to the brain, we identified 50 148 patients (aged 66 years and older) diagnosed with brain metastases between 2005 and 2016. We calculated the incidence, timing, and predictors of hospice enrollment using descriptive techniques and multivariable logistic regression. All statistical tests were 2-sided.
The incidence of hospice enrollment was 71.4% (95% confidence interval [CI] = 71.0 to 71.9; P < .001), a rate that increased over the study period (P < .001). The odds of enrollment for black (odds ratio [OR] = 0.76, 95% CI = 0.71 to 0.82; P < .001), Hispanic (OR = 0.80, 95% CI = 0.72 to 0.87; P < .001), and Asian patients (OR = 0.52, 95% CI = 0.48 to 0.57; P < .001) were substantially lower than white patients; men were less likely to be enrolled in hospice than women (OR = 0.78, 95% CI = 0.74 to 0.81; P < .001). Among patients enrolled in hospice, 32.6% (95% CI = 32.1 to 33.1; P < .001) were enrolled less than 7 days prior to death, a rate that was stable over the study period.
Hospice is used for a majority of elderly patients with brain metastases although a considerable percentage of patients die without hospice services. Many patients enroll in hospice late and, concerningly, statistically significant sociodemographic disparities exist in hospice utilization. Further investigations to facilitate targeted interventions addressing such disparities are warranted.
脑转移与相当大的发病率和死亡率有关。临终关怀的整合在生命末期为患者提供症状缓解，并提高生活质量，尤其是对于那些不太能够耐受脑部定向治疗的老年患者。关于老年脑转移患者临终关怀利用的人群水平调查有限。
我们使用监测、流行病学和最终结果-医疗保险数据库，对常见脑转移的原发癌部位进行分析，确定了 50148 名（年龄 66 岁及以上）2005 年至 2016 年间诊断为脑转移的患者。我们使用描述性技术和多变量逻辑回归计算了临终关怀入院的发生率、时间和预测因素。所有统计检验均为双侧。
临终关怀入院率为 71.4%（95%置信区间[CI]为 71.0 至 71.9；P<.001），该比率在研究期间有所增加（P<.001）。黑人（比值比[OR] = 0.76，95%CI = 0.71 至 0.82；P<.001）、西班牙裔（OR = 0.80，95%CI = 0.72 至 0.87；P<.001）和亚洲患者（OR = 0.52，95%CI = 0.48 至 0.57；P<.001）的入院几率明显低于白人患者；男性比女性更不可能被收容到临终关怀机构（OR = 0.78，95%CI = 0.74 至 0.81；P<.001）。在被收容到临终关怀的患者中，32.6%（95%CI = 32.1 至 33.1；P<.001）是在死亡前不到 7 天入院的，这一比例在研究期间保持稳定。
尽管有相当一部分患者在没有临终关怀服务的情况下死亡，但大多数老年脑转移患者仍使用临终关怀。许多患者在临终关怀中晚期入院，令人担忧的是，临终关怀的使用存在统计学上显著的社会人口学差异。需要进一步的调查来促进解决这些差异的有针对性的干预措施。
