Kassam Alisha, Gupta Abha, Rapoport Adam, Srikanthan Amirrtha, Sutradhar Rinku, Luo Jin, Widger Kimberley, Wolfe Joanne, Earle Craig, Gupta Sumit
Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
Department of Pediatrics and Division of Palliative Care, Southlake Regional Health Centre, Newmarket, ON, Canada.
J Clin Oncol. 2021 Aug 1;39(22):2506-2515. doi: 10.1200/JCO.20.03698. Epub 2021 Jun 7.
Evidence suggests that adolescents and young adults (AYAs) with cancer (defined as age 15-39 years) receive high-intensity (HI) medical care at the end-of-life (EOL). Previous population-level studies are limited and lack information on the impact of palliative care (PC) provision. We evaluated prevalence and predictors of HI-EOL care in AYAs with cancer in Ontario, Canada. A secondary aim was to evaluate the impact of PC physicians on the intensity of EOL care in AYAs.
A retrospective decedent cohort of AYAs with cancer who died between 2000 and 2017 in Ontario, Canada, was assembled using a provincial registry and linked to population-based health care data. On the basis of previous studies, the primary composite measure HI-EOL care included any of the following: intravenous chemotherapy < 14 days from death, more than one emergency department visit, and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death) and PC physician involvement. We determined predictors of outcomes using appropriate regression models.
Of 7,122 AYAs, 43.8% experienced HI-EOL care. PC physician involvement (odds ratio [OR], 0.57; 95% CI, 0.51 to 0.63) and older age at death (OR, 0.60; 95% CI, 0.48 to 0.74) were associated with a lower risk of HI-EOL care. AYAs with hematologic malignancies were at highest risk for HI and MI-EOL care. PC physician involvement substantially reduced the odds of mechanical ventilation at EOL (OR, 0.36; 95% CI, 0.30 to 0.43).
A large proportion of AYAs with cancer experience HI-EOL care. Our study provides strong evidence that PC physician involvement can help mitigate the risk of HI and MI-EOL care in AYAs with cancer.
有证据表明，患有癌症的青少年及青年成人（年龄定义为15 - 39岁）在生命末期（EOL）接受高强度（HI）医疗护理。以往的人群层面研究有限，且缺乏关于姑息治疗（PC）提供情况影响的信息。我们评估了加拿大安大略省患有癌症的青少年及青年成人中HI - EOL护理的患病率及预测因素。第二个目标是评估PC医生对青少年及青年成人EOL护理强度的影响。
使用省级登记系统组建了一个2000年至2017年间在加拿大安大略省死亡的患有癌症的青少年及青年成人回顾性死亡队列，并将其与基于人群的医疗保健数据相链接。根据以往研究，HI - EOL护理的主要综合指标包括以下任何一项：死亡前14天内进行静脉化疗、不止一次急诊就诊、死亡前30天内不止一次住院或入住重症监护病房。次要指标包括最具侵入性（MI）的EOL护理（例如，死亡前14天内进行机械通气）以及PC医生的参与情况。我们使用适当的回归模型确定结果的预测因素。
在7122名青少年及青年成人中，43.8%经历了HI - EOL护理。PC医生的参与（比值比[OR]，0.57；95%置信区间[CI]，0.51至0.63）以及较高的死亡年龄（OR，0.60；95% CI，0.48至0.74）与较低的HI - EOL护理风险相关。患有血液系统恶性肿瘤的青少年及青年成人发生HI和MI - EOL护理的风险最高。PC医生的参与显著降低了EOL时机械通气的几率（OR，0.36；95% CI，0.30至0.43）。
很大一部分患有癌症的青少年及青年成人经历HI - EOL护理。我们的研究提供了有力证据，表明PC医生的参与有助于降低患有癌症的青少年及青年成人发生HI和MI - EOL护理的风险。
