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Original Research |

End-of-Life Care Discussions Among Patients With Advanced Cancer: A Cohort Study

Jennifer W. Mack, MD, MPH; Angel Cronin, MS; Nathan Taback, PhD; Haiden A. Huskamp, PhD; Nancy L. Keating, MD, MPH; Jennifer L. Malin, MD, PhD; Craig C. Earle, MD, MSc; and Jane C. Weeks, MD, MSc
[+] Article, Author, and Disclosure Information

From Dana-Farber Cancer Institute, Children's Hospital, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts; Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California; and Ontario Institute for Cancer Research, Toronto, Ontario, Canada.

Grant Support: The work of the CanCORS Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (grant U01 CA093332 to the Dana-Farber Cancer Institute/Cancer Research Network, grant U01 CA093324 to Harvard Medical School/Northern California Cancer Center, grant U01 CA093348 to RAND/University of California, Los Angeles, grant U01 CA093329 to the University of Alabama at Birmingham, grant U01 CA093339 to the University of Iowa, grant U01 CA093326 to University of North Carolina) and by grant CRS 02-164 from the Department of Veterans Affairs to the Durham Veterans Affairs Medical Center. Dr. Mack was funded by an American Cancer Society Mentored Research Scholar Grant and by the National Palliative Care Research Center.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1622.

Reproducible Research Statement:Study protocol: Available on request at www.cancors.org/public/pub. Statistical code: Available from Dr. Mack (e-mail, jennifer_mack@dfci.harvard.edu). Data set: Not available.

Requests for Single Reprints: Jennifer W. Mack, MD, MPH, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215.

Current Author Addresses: Drs. Mack, Taback, and Weeks and Ms. Cronin: Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215.

Drs. Huskamp and Keating: Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115-5899.

Dr. Malin: Division of Hematology-Oncology (111-H), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Dr. Earle: Cancer Care Ontario and the Ontario Institute for Cancer Research, Office: Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, G Wing 106, Toronto, Ontario M4N 3M5, Canada.

Author Contributions: Conception and design: J.W. Mack, J.L. Malin, C.C. Earle, J.C. Weeks.

Analysis and interpretation of the data: J.W. Mack, A. Cronin, N. Taback, H.A. Huskamp, N.L. Keating, J.L. Malin, C.C. Earle, J.C. Weeks.

Drafting of the article: J.W. Mack, A. Cronin, N.L. Keating.

Critical revision of the article for important intellectual content: J.W. Mack, H.A. Huskamp, N.L. Keating, J.L. Malin, C.C. Earle, J.C. Weeks.

Final approval of the article: J.W. Mack, A. Cronin, N. Taback, H.A. Huskamp, N.L. Keating, J.L. Malin, C.C. Earle, J.C. Weeks.

Provision of study materials or patients: J.C. Weeks.

Statistical expertise: A. Cronin, N. Taback.

Obtaining of funding: J.C. Weeks.

Collection and assembly of data: A. Cronin, J.L. Malin, J.C. Weeks.

Ann Intern Med. 2012;156(3):204-210. doi:10.7326/0003-4819-156-3-201202070-00008
Text Size: A A A

Background: National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients with cancer whose life expectancy is less than 1 year.

Objective: To evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions take place.

Design: Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005.

Setting: Participants lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites.

Patients: 2155 patients with stage IV lung or colorectal cancer.

Measurements: End-of-life care discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis.

Results: 73% of patients had EOL care discussions identified by at least 1 source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death.

Limitations: The depth and quality of EOL care discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained.

Conclusion: Although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness.

Primary Funding Source: National Cancer Institute and Department of Veterans Affairs.


Grahic Jump Location
Appendix Figure 1.
Study design.

The box plots show the median time from diagnosis to completion of baseline and follow-up interviews.

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Appendix Figure 2.
Study flow diagram.

The CanCORS study response rate, which accounts for both unsuccessful contacts and refusal or nonresponse, was 51.0%. The cooperation rate, which does not account for unsuccessful contacts, was 59.9% (12). Please see definitions provided by the American Association for Public Opinion Research for details of calculation of response and cooperation rates (19). CanCORS = Cancer Outcomes Research and Surveillance Consortium; CRC = colorectal cancer.

Grahic Jump Location




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Submit a Comment/Letter
Duration of relationship and accuracy of prognosis
Posted on February 7, 2012
Stephen R, Workman, MD
Dalhousie University
Conflict of Interest: None Declared

Mack et al propose that "Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."

Prognosis however is tricky to estimate and physicians may be subject to bias. In a study examining prognostic accuracy Christakis et al concluded that

"Moreover,the better the doctor knew the patient--as measured, for example, by the length and recentness of their contact--the more likely the doctor was to err."(1)


1: Christakis NA, Lamont EB. Extent and determinants of error in doctors'prognoses in terminally ill patients: prospective cohort study. BMJ. 2000 Feb 19;320(7233):469-72. PubMed PMID: 10678857; PubMed Central PMCID: PMC27288.

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

End-of-Life Care Discussions Between Patients With Advanced Cancer and Doctors

The full report is titled “End-of-Life Care Discussions Among Patients With Advanced Cancer. A Cohort Study.” It is in the 7 February 2012 issue of Annals of Internal Medicine (volume 156, pages 204-210). The authors are J.W. Mack, A. Cronin, N. Taback, H.A. Huskamp, N.L. Keating, J.L. Malin, C.C. Earle, and J.C. Weeks.


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