Ezekiel J. Emanuel, MD, PhD; Yinong Young-Xu, MA; Norman G. Levinsky, MD; Gail Gazelle, MD; Olga Saynina, MA; Arlene S. Ash, PhD
Disclaimer: The opinions expressed are those of the authors and do not necessarily reflect the opinions or policies of the National Institutes of Health or the U.S. Department of Health and Human Services.
Acknowledgments: The authors thank Joan Warren, Deborah Schrag, and Peter Bach for helpful advice and comments on the project and manuscript. They also thank many questioners at the 2001 Annual American Society of Clinical Oncology meeting for helpful challenges.
Grant Support: This study was conducted under a contract from the Department of Clinical Bioethics, Clinical Center, National Institutes of Health to the Boston University School of Medicine and by a grant from the National Institutes of Aging.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Ezekiel J. Emanuel, MD, PhD, Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, Building 10, Room 1C118, Bethesda, MD 20892-1156.
Current Author Addresses: Dr. Emanuel: Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, Building 10, Room 1C118, Bethesda, MD 20892-1156.
Mr. Young-Xu: Harvard University, School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Dr. Levinsky: Boston University Medical Center, 715 Albany Street, Boston, MA 02118.
Dr. Gazelle: Harvard Vanguard Medical Association, 133 Brookline Avenue, Boston, MA 02215.
Ms. Saynina: National Bureau of Economic Research, 30 Alta Road, Stanford, CA 94305.
Dr. Ash: Boston University School of Medicine, 720 Harrison Avenue, #1108, Boston, MA 02118.
Author Contributions: Conception and design: E.J. Emanuel, G. Gazelle, A.S. Ash.
Analysis and interpretation of data: E.J. Emanuel, Y. Young-Xu, N.G. Levinsky, G. Gazelle, O. Saynina, A.S. Ash.
Drafting of the article: E.J. Emanuel, Y. Young-Xu, N.G. Levinsky, G. Gazelle, A.S. Ash.
Critical revision of the article for important intellectual content: E.J. Emanuel, Y. Young-Xu, N.G. Levinsky, G. Gazelle, A.S. Ash.
Final approval of the article: E.J. Emanuel, Y. Young-Xu, N.G. Levinsky, G. Gazelle, A.S. Ash.
Statistical expertise: A.S. Ash.
Obtaining of funding: E.J. Emanuel.
Collection and assembly of data: Y. Young-Xu.
Although many observers believe that cancer chemotherapy is overused at the end of life, there are no published data on this.
To determine the frequency and duration of chemotherapy use in the last 6 months of life stratified by type of cancer, age, and sex.
Retrospective cohort analysis.
Administrative databases from Massachusetts and California.
All Medicare patients who died of cancer in Massachusetts and 5% of Medicare cancer decedents in California in 1996.
Use of intravenous chemotherapy agents, chemotherapy administration, or medical evaluation for chemotherapy from Medicare billing data for each patient in 30-day periods from the date of death backward.
In Massachusetts, 33% of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life, 23% in the last 3 months, and 9% in the last month. In California, the percentages were 26%, 20%, and 9%, respectively. Chemotherapy use greatly declined with age. Chemotherapy use was similar for patients with breast, colon, and ovarian cancer and those with cancer generally considered unresponsive to chemotherapy, such as pancreatic, hepatocellular, or renal-cell cancer or melanoma. Patients with types of cancer that are unresponsive to chemotherapy had shorter duration of chemotherapy use.
Among patients who died of cancer, chemotherapy was used frequently in the last 3 months of life. The cancer's responsiveness to chemotherapy does not seem to influence whether dying patients receive chemotherapy at the end of life.
Some worry that physicians prescribe chemotherapy for patients with cancer at the end of life even when treatment is unlikely to prolong life or palliate symptoms.
Among the study sample of Medicare beneficiaries who died of cancer in 1996, the proportions that received chemotherapy were about 30%, 20%, and 10% in the last 6, 3, and 1 months of life. Chemotherapy use was similar for types of cancer that usually respond to chemotherapy and those that do not.
During the last 6 months of life, many Medicare beneficiaries with cancer receive chemotherapy, regardless of the type of cancer they have. Unfortunately, this study does not tell us why.
Table 1. Characteristics of Cancer Decedents in Massachusetts and California by Receipt of Chemotherapy in the Last 6 Months of Life
Table 2. Massachusetts Cancer Decedents Receiving Chemotherapy in the Last 6 Months of Life and Duration of Chemotherapy
Appendix Table. Massachusetts Cancer Decedents Receiving Chemotherapy in the Last 3 Months of Life, by Cancer Type and Age
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Emanuel EJ, Young-Xu Y, Levinsky NG, Gazelle G, Saynina O, Ash AS. Chemotherapy Use among Medicare Beneficiaries at the End of Life. Ann Intern Med. 2003;138:639–643. doi: 10.7326/0003-4819-138-8-200304150-00011
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Published: Ann Intern Med. 2003;138(8):639-643.
End-of-Life Care, Healthcare Delivery and Policy, Hematology/Oncology.
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