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Cancer care: "Tragic underservice"

By Matthew C. Wiencke

This is one of the maps in a new Dartmouth Atlas report focused on cancer care.

A new report by the Dartmouth Atlas Project, the first to focus specifically on cancer care, shows that whether patients with advanced cancer die in a hospital or while receiving hospice care varies greatly across regions and academic medical centers.

The Dartmouth researchers studied 235,821 Medicare patients age 65 or older with aggressive or metastatic cancer who died between 2003 and 2007. They found that in many parts of the country, over a third of patients spent their last days in hospitals; the range was from a high of 46.7% in Manhattan to a low of 19.6% in Fort Lauderdale, Fla. Many of the hospitalized patients received aggressive care, such as feeding tubes. And although chemotherapy was used in the last two weeks of life for 6% of all patients nationwide, in some areas the rate exceeded 10%; in Olympia, Wash., for example, it was 12.6%.

Patients' care varied in other ways as well. For example, over 40% of patients were admitted to intensive care during the last month of life in Huntsville, Ala., but only 6% in Mason City, Iowa.

Intensive: There were variations in care even for patients hospitalized in academic medical centers. For example, 46.1% of patients were admitted to intensive care in the last month of life at St. John Hospital and Medical Center in Detroit, compared to only 8.9% of patients at Memorial Sloan-Kettering in Manhattan. In at least 50 academic medical centers, less than half of these patients with advanced cancer were receiving hospice services.

Patients, the researchers argue in their report, need to be made more aware of their choices and of what those choices mean. "Many patients find little opportunity to explore these preferences as the clinical team 'fights' the battle against an illness that has no cure," the authors wrote. "The slow pace of adoption of early palliative care for patients with serious cancer is a tragic underservice of health care, leading to much unnecessary suffering."

"When it's likely to be a very shortened life span," says lead author David Goodman, M.D., "patients want to understand how they can live long, but also how they can live well."

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