Fix&J, &es&t, MB, ~~nys~ Adler, MA, ~e~~~l~g Gray, EdD, Maureen A. Ryan, MSN, Joseph Chino, MD, and Ravinder Mamtani,
MD Calvary Hos#al (F.J.B., D.A., G.G., M.A.R.), Brim; and New York Medical College (J.C., R.M.), Whalla, NOWYork
Although debate continues regarding the extent of progress made against cancer, this disease remains a formidabIe problem in the United States, with a mortality rate of 50%’ Despite advances in treatment, the age-acljusted martality rates hove increased in the past 20 years by nearly 9%~~ These 11~~1~~1~~~~ pzztients rn~: spend some period of time (from weeks to JYW-s)sufkring the di%cult and diverse symptoms that accompany progressive malignancy. Traditional!y. ponents with advanced cancer have not been the focus of major research interAddress repi?&trequeststo: f+ankJ. Brescia, MD, Caivat-y Hospital, 10461.
1740 Fast&ester
Road,
Bronx,
Acceptedfor publication: September 5, 1989.
8 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier, New York, New York
NY
est. The development of the hospice movement brought attention to the care of the dying, but few large-scale reports profile the patient experience.ss” moreover, the focus of most palliative care programs in suburban commu~~ies is on providing services in the borne setting. There is less emphasis on terminal patients requiring hospitalization. This article profiks a large population of advanced cancer patients referred to Calvary hospice, which cares exclaisively fkr t.hose individuals in the terminal stages of disease.
The goals of the study were to devetop a clinical data base model for advanced cancer and identify whether significant relationships exist among demographic, treatment, and cbutcome
O&385-3924/90/$3.50
variables. It was anticipated that the project would &se a variety of questions and issues for future studies. Most patients admitted to Calvary Hospital die within days to weeks. Conventional and expeGmental therapy are no longer considered beneficial, and patients have multiple progressive physical problems. Patients reside in a region where there is access to excellent oncologic inpatient and outpatient services, as well as consultat~o~~ the majority of ~tien~ (77%~ are transferrod from other inpatient hospital scttings in the metropolitan New York area, and r~~~~~~t direct admission from only 22 home. ~~ause uf the obvious severity of illness ved inability to remain at home, these squire hosp~~li~atiorl during the s. uestions for study were developed, and the data ne~ed to answer these questions were identified. A decision was made to use information recorded in the medical chart to facilitate access and enabie return to the charts for verification. Thus, the presence or absence of symptoms was determined from the patient’s medical record and not from direct clinical asBurnett. Symptoms identity in~tuded pain @everet mild, or none), nausea, anorexia, dyspita, and ~~~n~ss sf breath. Based on the selection of these variables~ a data collection form was designed. Seventy-two
abstract seat by the referring hospital and the initial assessme~c of Calvary Hospital stafK Charts were reviewed again soon after the patient’s death or discharge. Data comparable to those obtained at a$mission were recorded for the intervals 2 weeks prior to death and each of the last li days of life. All inflation was entered into a PC-AT using Data Ease software. §tatistical techniques included frequency distributions, chi square, z scores, and re ssion anaiyses.
years), and nearly 10% were over 35 years of age. Fifiy-nine ~erceat were female. Married patients accounted for 36% of the total, while the remaining were widuwcd j35%), single f16%), divorced (S%), or separated (5%). Seventy percent of ttne study population were white, with the remainder black fZS%), Hispanic (6%), and Asian (1%). As noted, 77% of patients were transferred from other hospitals, and 22% were admitted from home; only 1% were admitted from a nutmeg home. Thirty percent of the patients lived alone prior to hospitalization; 67% lived with others (spouse 36%, child 19%, relatives it)%, friends 2%), and 3% lived in institutions. Most patients (92%) died at Calvary, while the remaining 8% were discharged either to home ), nll~~~lg home (2 ), or another hospital ). The median length of stay at Cafvary Hospital was 26 days, with the rnea~ 44 days, and a range of a few hours to more than 121 days during this study. Twenty percent of the patients expired within 1 week of their admission. The most common diagnoses in the study population (Table 1) reflect the national statistics on p~l~ary cancer sites5 The most frequent cancers were lung (19%), breast (IS%), colon (lQ%), and rectum (6%). Each of the following diagnoses represented 3%-5% of the population: prostate, pancreas, head and neck, cervix, ovary, and stomach. The clinically documented and symptomatic metas~ti~ sites were identified in relation to the leading diagnoses flable 2). Metastasis to the bone was present in 3~% of the patients; met~stases to the lung (24%), liver (28%), and brain (17%) were also common. Many patients had metastasis to more than one site, with accompanying symp toms.
Diagnoses Lung Breast
Colon This sport describes the 1,163 in~tie~ts who were admitted to Calvary Hospital from Julr 1, 1985, through June 36, 1936, and who died or were discharged by December 31,1986, A majority(62%) of these patients were over 65 Years of age Oange: 24-94 years; mean 68
&vrirm anrl AywGA Prostate Pancreas Head and neck Cervix -ary Stomach
Number (%) 210 139 114 69 60 48 45 44 34 30
(19) (IS) (10) (6) (55) (41 (41 (4) (3) (3)
Percentof
Site (n =J n,no3) Percent Bone
Liver
Lung
Brain
38
28
24
17
21 25 56 51 12 46 4 18 29 33
31 34 26 28 17 6
39 28 11 9
Proportion of patients with involvement on admission Leading diagnoses Lung Breast Colon Rectum and sigmoid Prostate Pancreas Head and neck Cervix Qvary
_
BI 14 17 94
4 18 18 9 10
Storn~~h
Almost all patients (99%) were capable of only limited self-care and were confined to bed or chair for most of their waking hours. Most of the common symptoms of advanced disease were present in this population. &e-third were grossly confused on admission; these patients all had at least one episode of extreme confusion or diso~entation reported during the first 24 hr after admission. The presence of confusion increased in the decades over 65 ycxs
of age, with patients ovel’ ‘75 years of age
more likely to ttxhibit this symptom (p c 0.00 I). Slighdy less than one-third (31%) of the patients su@ered from anorexia. As anticipated, over half (54%) the patients with pancreatic cancer had this symptom. Nineteen percent of the sample experienced nausea, and patients with ovarian cancer had the highest incidence {56%). Shortness of breath was recorded in 27% of the patients. The prevalence of anorex-
:: 18 7
; 2 1 13
ia, nausea, and shortness of breath did not vary with age. Patients under 65 years of age were sigl&rantly more likely than older parients to have dysphagia Cp < 0.05) (Tabl’c 3).
For purposes of this study, severe pain was defined as recorded pain of moderate or greater intensity that occurred with regularity throughout the day. Mild pain was noted when the record stated that pain was relieved without the use of analgesics, by nonnarcotic analgesics, or by narcotics of mild potency (e.g., codeine). No pain was noted when tbe record stated explicitly that the patient offered no compfaints of pain and that he or she was comfortable. Fain was a problem at admission for 73% of the patients, and 38% of the total study population had severe pain. Cancer of the cervix was the diagnosis most frequently (68%) associated
Table 3 Selected Symptoms on Admission to Calvary Hospital by Age (n = 1,103) Percent
Total Patients Anorexia Dysphagia* Nausea Shortness of breath Severe pain* Confusion* *Significant difference.
;; 19 27 38 33
65 yr (n = 689)
30 21 20 26 47 29
31 16 19 27 33 35
_-.
Brescia et al.
224
Jwnal
of Pain and S~mptamManagement
80 70 60 z
50
0
40
ii!
30 20 10
Paln
0 a36
38.. 44
4664
66~~~~3
36. 74
?684
with severe pain on admission Patients with posits, as well as r~tali and sigmoid cancers, also had a high f~quency of severe pain on odand 49%, respectively). Severe rted by half (49%) of the patients admitted with bone metastasis, but by only onethird (91%) of the patients without bone involvement. Severe pain was more often reported to be a problem for patients coming from home than for those coming fmm referring hospitals (p e: 6.661) (Table 4). The data were analyzed to determine the rel~tj~nshi~ ~tween and pain. The reportre pain was found to be inve~ly Figure 1). pain was described by between 55 and 74 years of age; nts under 55 most often reported WVCE while thase over 75 experienced this problem kast often fp < 6.~~~. ~ven~~ne percent of patients with cervical cancer, the tumor 4
LocationISor to Admiiion b Pain Admission (a = 1,099)*
Level on
Fig. 1. Pain level on admission (n =i 1,lO~).
*86
most often associated with severe pain, tY were under 65 years of age.
The vast majority (89%) of patients had received some therapy (surgery, radiotherapy, or ch~rn~~the~py~directed against their malignancy prior to their referral to Calvary Hospital. The curative or palliative intent and the timing of this previous therapy was not known. Whether tre_;\tment was experimental or conventional, and whether appropriate dosing was employed were also not studied. Of the 116 patients who received no anticancer therapy prior to admission, 3 1% had lung or pancreatic malignancies. Eighty-three percent of the untreated patients were over 65 years old (Table 5); patients over 75 were less likely to have received either chemothe~py @ < O.OOl),radiotherapy @ < 0.001) or surgery f,p < 0.01) prior to admission. Sixty-three percent of the untreated patients died within 6 months of diagnosis, as compared to 24% of the total population.
Percent No Fain
Mild
severp
Total Patients
27
35
38
H~~i~*~ (845) Home** (240) Nursing home (14)
29
36 31 21
:: 29
ff!!
*FourPatientsadmitti bornothersources. **s+ficant Merences p < 0.091.
Most patients (92%) died, as expected, Following referral to this palliative care setting. The length of survival, i.e., the interval from time of diagnosis to death, was examined. Twenty-four percent of the patients at Calvary had been diagnosed with cancer 6 months or less prior to their death. The primary tumor sites associated with a shorter survival time were lung, pancre-
~e~a~o~jp
Table5 of Age and Prior T~at~en~ - ___-_..
(7~= 1,163) Percent
Total patients Under 65 y r (4 14) 65-74 yr (310) 75-84 yr (276) 85+ yr (103)
,_
Chemo, chemothe~py;
Some Prior Treatment
Rt
Surgery
89 95 93 64 76
63 75 67 50 29
z 67 61 52
and Rt, ~diation
therapy.
cancers; 65% admitted with lung cancer, 78% af those with stoma~b cancer,
as, and stomach
failure (e.g., hypercalcemia, lycemia) addedanother 4% and 3%, res y. Qnly 2% of patinas were thought clinically to s cumb frol~ a nontumor cause, and tbe cause of death was unclear in 6% of the cases.
and 84% of those with pancreatic cancer died within 1 year of d~ag~~s~s (Table 6). fBf 2 10 patients with advanced lung cancer, the me,dian survivals of adenocarcinoma (n ‘- 751, squamous cell carcinoma (n = 45) ano b~aall/oat cell carcinoma (n = 37) were 6.6 months, 8.1 months, and IO months, respectively. Survival was inversely related ito age @ < 0.01). Patients under 74 years of age were more likely to survive longer than patic& 75 and older. The immediate cause of death was determined to be organ failure in 70% of the 524 patients for whom such data were available. This determination was made t !f the attending clinician without the benefit of p>sthclogic examination. Infection accounted for 13% of these deaths, while hemorrhage and metabolic
This study examined a large ~pu~ation of patients in an urban setting who were admitted to a specialty hospital for advanced malignancy. T&e short length of survival of these patients reflects the selection process, which focuses on extremely ill patients who, for a variety of reasons, cannot be managed at home. Tumors in this study yopulation exhibited aggressive natural histories, as noted by their survival time; 25% of patients died within 6 mont~~s and 42% died within i year of initial d~gn~~sis. However, the time from the initial
TubL 6 Relationship of Diagnoses to Length of Survival (Diagnosis to Death) (n = 1,107) D~Jr~tion Of FmoosC
mo
7-12
l-2
yr
iheSS
(in %)
4-3 yr
3-5 yr
5-10 yr
lO+=
Total patients
24
18
21
10
13
10
4
Leading diagnoses Lung Breast Colon
39 5 15
26 5 12
21 I& 24
7 14 11
5 21 26
2; 8
1 12 4
16 4 54 17 8 19 50
16 3:
24 20 9 31 38 16 11
19 8 ;
19 31 2 7 14 16 11
2: 0 IO 16 10 0
: n 5 5 3 6
Rectum and sigmoid Prostate Pancreas Head and neck Cervix Ovary Stomach
29 11 16 28
6 19 0
226
Brescia et
symptoms to a diagnosis of cancer was not known. This information would be helpful, especially since many geriatric, minority, and single patients do not have adequate access to health care, and for some of these patients, the short ~~mival may have been the result of a late stage at the time of diagnosis. The admission process described above resulted in a population whose median survival was only S weeks after admission. Respite this, of the patients were able to be discha~~~d~ tie& conditions were responsive: to or supportive treatment; some responded to earlier anticancer therapy, and in other cases, patients no longer citation for ~ympton~ csntrol. were transferred back to the referring institutions or nursing homes as their condition required, A seeable num~r ~22%)of the patients were admitted di~ctly from home. This reflects the increasing use of the home as the location for terminal care, even in an urban setting. Symptom control is the essence of good medical, as well as palliative care, Pain is the issue of greatest concern to patients, families, and caregivers. ~v~nty-thy percent of the patients in the study had pain on admission. This is consistudies reporting pain to be a of terminal cancer pauch as diagnosis, age, and me~static involvements arn~~g others, influetacccthe presence and extent of pain. Awareness of the relationship sf specific diagnoses h these symptoms permits the planning and ssary for their amelioration. uthors are cu~ntly evaluating analgesic prior to the patient’s death in this population. A majority (62%) of the patients were persons over 65 years of age. Of interest was the large patron (10%) over 85. Cancer is the second leading cause of death in adults tfver 65 years old-$ In this study population, the major changes appeared after age 75, instead of 65, the age usually used to define the “older” patient. While some symptoms (anorexia, nausea, aud sho~n~s of beak) were represented equally in all age pups, others differed sign& -fly by age. pain apPeared to be less of a problem for older patients, consistent with the findings of the National Hospice Study.1*
Journal of Pa& and SympwrtManagenmt
al.
Another issue strongly related to age was the likelihood of receiving antitumor therapy. Of the total population studied, 11% received no prior anticancer therapy, consistent witb results reported elsewhere (personal co~~spo~dence, National Cancer Institute). Of these untreated patients, 88% were over 65 years of age. In some cases, patients or families may have refused further int~~ention followiR~ a diagno&s of cartcer. Alt~natively, m~ical decisions not to treat these older patients may have been the result of a realistic appraisal of the patient’s inability to tolerate attd respond to a therapeutic regimen. It could ntat be known whether nonical rea~ns, e.g., tr~s~rtation, crucial p~bl~~~s, or lack of family support, added to More information regarding the imtnediate cause of death would be helpful to the clinician. However, approval for an autopsy is diflicult to obtain in patients known to be dying of cancer in a palliative environment. Because few patients had hematologic cancer and/or recent cytotoxic treatment, there may have been fewet infection-related deaths thau were reported in a previous study of morality done at a major cancer h~pital.lt In summary, patients admitted to Calvary Hospital generally have solid rumors with aggressive natural histories. Survival is short, and patients suffer the well-described symptoms of advanced disease. Whether this dying group of patients could have remained at home with improved resources could not be determined by this study. The large number uf patients, and the prevalence and severity of problems suggest that there is a ~ntinuing need for specialized palliative care institutions, such as CalvaryHOSpital.
cted at Calvary Hospital, Bronx, New York, and was supported by an American Cancer Society, Cancer Control Grant No. 237. ?f ales 1. American Cancer Society: Cancer facts ;dnd figures: 1988. New York: American Cancer Society, 1988:3.
Vol. 5 No. 4 August 1990
HospitalizedA&dancedCancer Patients
22;
2. American Cancer Society: Cancer statistics, 1988. CA 1988:38:22.
vanced cancer: pain relief. London: Limited 1X0:6.
3. Kane R. Wales J, Bernstein L. A randomized controlled trial of hospice care. Lancet 1984;2:890-894.
8. Bonica J. Treatment of cancer pain: current status and future needs in advances in pain research and therapy, vol 9. In: Fields H, Dubner R, Cervero F, eds. New York: Raven, 1985:592.
4. Freer D, Morv, Morris J. An alternative in terminal care: results of the national hospice study. J Chronic Dis 1986;39:9- 2% 5. U.S. Dept. of Health and Human Services: Cancer incidence and mortality in the United States-SEER Program-19731981. Bethesda, Md; National Cancer Institute, 1984. 6. Foley K, The treatment Med 1985;313:84.
of cancer pain. N Engl J
7. ‘I’wycross 8, Lack S. Symptom coutrol iii far ad-
Pitman Books
9. Yancik R. Perspectives on prevention and treatment of cancer in the elderly. New York: Raven, 1983. 10. Morris J, Mor Y, Goldberg R. The effect of treatment setting and patient characteristics on pain in terminal cancer patients: a report from the national hospice study. J Chronic Dis 1986:39:32. 11. hag&i J, Rudriquez V, Rodey C. Causes !~f dcarlr in cancer patients. Callcer 1974:33:568-573.
MD Calvary Hos#al (F.J.B., D.A., G.G., M.A.R.), Brim; and New York Medical College (J.C., R.M.), Whalla, NOWYork
Although debate continues regarding the extent of progress made against cancer, this disease remains a formidabIe problem in the United States, with a mortality rate of 50%’ Despite advances in treatment, the age-acljusted martality rates hove increased in the past 20 years by nearly 9%~~ These 11~~1~~1~~~~ pzztients rn~: spend some period of time (from weeks to JYW-s)sufkring the di%cult and diverse symptoms that accompany progressive malignancy. Traditional!y. ponents with advanced cancer have not been the focus of major research interAddress repi?&trequeststo: f+ankJ. Brescia, MD, Caivat-y Hospital, 10461.
1740 Fast&ester
Road,
Bronx,
Acceptedfor publication: September 5, 1989.
8 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier, New York, New York
NY
est. The development of the hospice movement brought attention to the care of the dying, but few large-scale reports profile the patient experience.ss” moreover, the focus of most palliative care programs in suburban commu~~ies is on providing services in the borne setting. There is less emphasis on terminal patients requiring hospitalization. This article profiks a large population of advanced cancer patients referred to Calvary hospice, which cares exclaisively fkr t.hose individuals in the terminal stages of disease.
The goals of the study were to devetop a clinical data base model for advanced cancer and identify whether significant relationships exist among demographic, treatment, and cbutcome
O&385-3924/90/$3.50
variables. It was anticipated that the project would &se a variety of questions and issues for future studies. Most patients admitted to Calvary Hospital die within days to weeks. Conventional and expeGmental therapy are no longer considered beneficial, and patients have multiple progressive physical problems. Patients reside in a region where there is access to excellent oncologic inpatient and outpatient services, as well as consultat~o~~ the majority of ~tien~ (77%~ are transferrod from other inpatient hospital scttings in the metropolitan New York area, and r~~~~~~t direct admission from only 22 home. ~~ause uf the obvious severity of illness ved inability to remain at home, these squire hosp~~li~atiorl during the s. uestions for study were developed, and the data ne~ed to answer these questions were identified. A decision was made to use information recorded in the medical chart to facilitate access and enabie return to the charts for verification. Thus, the presence or absence of symptoms was determined from the patient’s medical record and not from direct clinical asBurnett. Symptoms identity in~tuded pain @everet mild, or none), nausea, anorexia, dyspita, and ~~~n~ss sf breath. Based on the selection of these variables~ a data collection form was designed. Seventy-two
abstract seat by the referring hospital and the initial assessme~c of Calvary Hospital stafK Charts were reviewed again soon after the patient’s death or discharge. Data comparable to those obtained at a$mission were recorded for the intervals 2 weeks prior to death and each of the last li days of life. All inflation was entered into a PC-AT using Data Ease software. §tatistical techniques included frequency distributions, chi square, z scores, and re ssion anaiyses.
years), and nearly 10% were over 35 years of age. Fifiy-nine ~erceat were female. Married patients accounted for 36% of the total, while the remaining were widuwcd j35%), single f16%), divorced (S%), or separated (5%). Seventy percent of ttne study population were white, with the remainder black fZS%), Hispanic (6%), and Asian (1%). As noted, 77% of patients were transferred from other hospitals, and 22% were admitted from home; only 1% were admitted from a nutmeg home. Thirty percent of the patients lived alone prior to hospitalization; 67% lived with others (spouse 36%, child 19%, relatives it)%, friends 2%), and 3% lived in institutions. Most patients (92%) died at Calvary, while the remaining 8% were discharged either to home ), nll~~~lg home (2 ), or another hospital ). The median length of stay at Cafvary Hospital was 26 days, with the rnea~ 44 days, and a range of a few hours to more than 121 days during this study. Twenty percent of the patients expired within 1 week of their admission. The most common diagnoses in the study population (Table 1) reflect the national statistics on p~l~ary cancer sites5 The most frequent cancers were lung (19%), breast (IS%), colon (lQ%), and rectum (6%). Each of the following diagnoses represented 3%-5% of the population: prostate, pancreas, head and neck, cervix, ovary, and stomach. The clinically documented and symptomatic metas~ti~ sites were identified in relation to the leading diagnoses flable 2). Metastasis to the bone was present in 3~% of the patients; met~stases to the lung (24%), liver (28%), and brain (17%) were also common. Many patients had metastasis to more than one site, with accompanying symp toms.
Diagnoses Lung Breast
Colon This sport describes the 1,163 in~tie~ts who were admitted to Calvary Hospital from Julr 1, 1985, through June 36, 1936, and who died or were discharged by December 31,1986, A majority(62%) of these patients were over 65 Years of age Oange: 24-94 years; mean 68
&vrirm anrl AywGA Prostate Pancreas Head and neck Cervix -ary Stomach
Number (%) 210 139 114 69 60 48 45 44 34 30
(19) (IS) (10) (6) (55) (41 (41 (4) (3) (3)
Percentof
Site (n =J n,no3) Percent Bone
Liver
Lung
Brain
38
28
24
17
21 25 56 51 12 46 4 18 29 33
31 34 26 28 17 6
39 28 11 9
Proportion of patients with involvement on admission Leading diagnoses Lung Breast Colon Rectum and sigmoid Prostate Pancreas Head and neck Cervix Qvary
_
BI 14 17 94
4 18 18 9 10
Storn~~h
Almost all patients (99%) were capable of only limited self-care and were confined to bed or chair for most of their waking hours. Most of the common symptoms of advanced disease were present in this population. &e-third were grossly confused on admission; these patients all had at least one episode of extreme confusion or diso~entation reported during the first 24 hr after admission. The presence of confusion increased in the decades over 65 ycxs
of age, with patients ovel’ ‘75 years of age
more likely to ttxhibit this symptom (p c 0.00 I). Slighdy less than one-third (31%) of the patients su@ered from anorexia. As anticipated, over half (54%) the patients with pancreatic cancer had this symptom. Nineteen percent of the sample experienced nausea, and patients with ovarian cancer had the highest incidence {56%). Shortness of breath was recorded in 27% of the patients. The prevalence of anorex-
:: 18 7
; 2 1 13
ia, nausea, and shortness of breath did not vary with age. Patients under 65 years of age were sigl&rantly more likely than older parients to have dysphagia Cp < 0.05) (Tabl’c 3).
For purposes of this study, severe pain was defined as recorded pain of moderate or greater intensity that occurred with regularity throughout the day. Mild pain was noted when the record stated that pain was relieved without the use of analgesics, by nonnarcotic analgesics, or by narcotics of mild potency (e.g., codeine). No pain was noted when tbe record stated explicitly that the patient offered no compfaints of pain and that he or she was comfortable. Fain was a problem at admission for 73% of the patients, and 38% of the total study population had severe pain. Cancer of the cervix was the diagnosis most frequently (68%) associated
Table 3 Selected Symptoms on Admission to Calvary Hospital by Age (n = 1,103) Percent
Total Patients Anorexia Dysphagia* Nausea Shortness of breath Severe pain* Confusion* *Significant difference.
;; 19 27 38 33
65 yr (n = 689)
30 21 20 26 47 29
31 16 19 27 33 35
_-.
Brescia et al.
224
Jwnal
of Pain and S~mptamManagement
80 70 60 z
50
0
40
ii!
30 20 10
Paln
0 a36
38.. 44
4664
66~~~~3
36. 74
?684
with severe pain on admission Patients with posits, as well as r~tali and sigmoid cancers, also had a high f~quency of severe pain on odand 49%, respectively). Severe rted by half (49%) of the patients admitted with bone metastasis, but by only onethird (91%) of the patients without bone involvement. Severe pain was more often reported to be a problem for patients coming from home than for those coming fmm referring hospitals (p e: 6.661) (Table 4). The data were analyzed to determine the rel~tj~nshi~ ~tween and pain. The reportre pain was found to be inve~ly Figure 1). pain was described by between 55 and 74 years of age; nts under 55 most often reported WVCE while thase over 75 experienced this problem kast often fp < 6.~~~. ~ven~~ne percent of patients with cervical cancer, the tumor 4
LocationISor to Admiiion b Pain Admission (a = 1,099)*
Level on
Fig. 1. Pain level on admission (n =i 1,lO~).
*86
most often associated with severe pain, tY were under 65 years of age.
The vast majority (89%) of patients had received some therapy (surgery, radiotherapy, or ch~rn~~the~py~directed against their malignancy prior to their referral to Calvary Hospital. The curative or palliative intent and the timing of this previous therapy was not known. Whether tre_;\tment was experimental or conventional, and whether appropriate dosing was employed were also not studied. Of the 116 patients who received no anticancer therapy prior to admission, 3 1% had lung or pancreatic malignancies. Eighty-three percent of the untreated patients were over 65 years old (Table 5); patients over 75 were less likely to have received either chemothe~py @ < O.OOl),radiotherapy @ < 0.001) or surgery f,p < 0.01) prior to admission. Sixty-three percent of the untreated patients died within 6 months of diagnosis, as compared to 24% of the total population.
Percent No Fain
Mild
severp
Total Patients
27
35
38
H~~i~*~ (845) Home** (240) Nursing home (14)
29
36 31 21
:: 29
ff!!
*FourPatientsadmitti bornothersources. **s+ficant Merences p < 0.091.
Most patients (92%) died, as expected, Following referral to this palliative care setting. The length of survival, i.e., the interval from time of diagnosis to death, was examined. Twenty-four percent of the patients at Calvary had been diagnosed with cancer 6 months or less prior to their death. The primary tumor sites associated with a shorter survival time were lung, pancre-
~e~a~o~jp
Table5 of Age and Prior T~at~en~ - ___-_..
(7~= 1,163) Percent
Total patients Under 65 y r (4 14) 65-74 yr (310) 75-84 yr (276) 85+ yr (103)
,_
Chemo, chemothe~py;
Some Prior Treatment
Rt
Surgery
89 95 93 64 76
63 75 67 50 29
z 67 61 52
and Rt, ~diation
therapy.
cancers; 65% admitted with lung cancer, 78% af those with stoma~b cancer,
as, and stomach
failure (e.g., hypercalcemia, lycemia) addedanother 4% and 3%, res y. Qnly 2% of patinas were thought clinically to s cumb frol~ a nontumor cause, and tbe cause of death was unclear in 6% of the cases.
and 84% of those with pancreatic cancer died within 1 year of d~ag~~s~s (Table 6). fBf 2 10 patients with advanced lung cancer, the me,dian survivals of adenocarcinoma (n ‘- 751, squamous cell carcinoma (n = 45) ano b~aall/oat cell carcinoma (n = 37) were 6.6 months, 8.1 months, and IO months, respectively. Survival was inversely related ito age @ < 0.01). Patients under 74 years of age were more likely to survive longer than patic& 75 and older. The immediate cause of death was determined to be organ failure in 70% of the 524 patients for whom such data were available. This determination was made t !f the attending clinician without the benefit of p>sthclogic examination. Infection accounted for 13% of these deaths, while hemorrhage and metabolic
This study examined a large ~pu~ation of patients in an urban setting who were admitted to a specialty hospital for advanced malignancy. T&e short length of survival of these patients reflects the selection process, which focuses on extremely ill patients who, for a variety of reasons, cannot be managed at home. Tumors in this study yopulation exhibited aggressive natural histories, as noted by their survival time; 25% of patients died within 6 mont~~s and 42% died within i year of initial d~gn~~sis. However, the time from the initial
TubL 6 Relationship of Diagnoses to Length of Survival (Diagnosis to Death) (n = 1,107) D~Jr~tion Of FmoosC
mo
7-12
l-2
yr
iheSS
(in %)
4-3 yr
3-5 yr
5-10 yr
lO+=
Total patients
24
18
21
10
13
10
4
Leading diagnoses Lung Breast Colon
39 5 15
26 5 12
21 I& 24
7 14 11
5 21 26
2; 8
1 12 4
16 4 54 17 8 19 50
16 3:
24 20 9 31 38 16 11
19 8 ;
19 31 2 7 14 16 11
2: 0 IO 16 10 0
: n 5 5 3 6
Rectum and sigmoid Prostate Pancreas Head and neck Cervix Ovary Stomach
29 11 16 28
6 19 0
226
Brescia et
symptoms to a diagnosis of cancer was not known. This information would be helpful, especially since many geriatric, minority, and single patients do not have adequate access to health care, and for some of these patients, the short ~~mival may have been the result of a late stage at the time of diagnosis. The admission process described above resulted in a population whose median survival was only S weeks after admission. Respite this, of the patients were able to be discha~~~d~ tie& conditions were responsive: to or supportive treatment; some responded to earlier anticancer therapy, and in other cases, patients no longer citation for ~ympton~ csntrol. were transferred back to the referring institutions or nursing homes as their condition required, A seeable num~r ~22%)of the patients were admitted di~ctly from home. This reflects the increasing use of the home as the location for terminal care, even in an urban setting. Symptom control is the essence of good medical, as well as palliative care, Pain is the issue of greatest concern to patients, families, and caregivers. ~v~nty-thy percent of the patients in the study had pain on admission. This is consistudies reporting pain to be a of terminal cancer pauch as diagnosis, age, and me~static involvements arn~~g others, influetacccthe presence and extent of pain. Awareness of the relationship sf specific diagnoses h these symptoms permits the planning and ssary for their amelioration. uthors are cu~ntly evaluating analgesic prior to the patient’s death in this population. A majority (62%) of the patients were persons over 65 years of age. Of interest was the large patron (10%) over 85. Cancer is the second leading cause of death in adults tfver 65 years old-$ In this study population, the major changes appeared after age 75, instead of 65, the age usually used to define the “older” patient. While some symptoms (anorexia, nausea, aud sho~n~s of beak) were represented equally in all age pups, others differed sign& -fly by age. pain apPeared to be less of a problem for older patients, consistent with the findings of the National Hospice Study.1*
Journal of Pa& and SympwrtManagenmt
al.
Another issue strongly related to age was the likelihood of receiving antitumor therapy. Of the total population studied, 11% received no prior anticancer therapy, consistent witb results reported elsewhere (personal co~~spo~dence, National Cancer Institute). Of these untreated patients, 88% were over 65 years of age. In some cases, patients or families may have refused further int~~ention followiR~ a diagno&s of cartcer. Alt~natively, m~ical decisions not to treat these older patients may have been the result of a realistic appraisal of the patient’s inability to tolerate attd respond to a therapeutic regimen. It could ntat be known whether nonical rea~ns, e.g., tr~s~rtation, crucial p~bl~~~s, or lack of family support, added to More information regarding the imtnediate cause of death would be helpful to the clinician. However, approval for an autopsy is diflicult to obtain in patients known to be dying of cancer in a palliative environment. Because few patients had hematologic cancer and/or recent cytotoxic treatment, there may have been fewet infection-related deaths thau were reported in a previous study of morality done at a major cancer h~pital.lt In summary, patients admitted to Calvary Hospital generally have solid rumors with aggressive natural histories. Survival is short, and patients suffer the well-described symptoms of advanced disease. Whether this dying group of patients could have remained at home with improved resources could not be determined by this study. The large number uf patients, and the prevalence and severity of problems suggest that there is a ~ntinuing need for specialized palliative care institutions, such as CalvaryHOSpital.
cted at Calvary Hospital, Bronx, New York, and was supported by an American Cancer Society, Cancer Control Grant No. 237. ?f ales 1. American Cancer Society: Cancer facts ;dnd figures: 1988. New York: American Cancer Society, 1988:3.
Vol. 5 No. 4 August 1990
HospitalizedA&dancedCancer Patients
22;
2. American Cancer Society: Cancer statistics, 1988. CA 1988:38:22.
vanced cancer: pain relief. London: Limited 1X0:6.
3. Kane R. Wales J, Bernstein L. A randomized controlled trial of hospice care. Lancet 1984;2:890-894.
8. Bonica J. Treatment of cancer pain: current status and future needs in advances in pain research and therapy, vol 9. In: Fields H, Dubner R, Cervero F, eds. New York: Raven, 1985:592.
4. Freer D, Morv, Morris J. An alternative in terminal care: results of the national hospice study. J Chronic Dis 1986;39:9- 2% 5. U.S. Dept. of Health and Human Services: Cancer incidence and mortality in the United States-SEER Program-19731981. Bethesda, Md; National Cancer Institute, 1984. 6. Foley K, The treatment Med 1985;313:84.
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7. ‘I’wycross 8, Lack S. Symptom coutrol iii far ad-
Pitman Books
9. Yancik R. Perspectives on prevention and treatment of cancer in the elderly. New York: Raven, 1983. 10. Morris J, Mor Y, Goldberg R. The effect of treatment setting and patient characteristics on pain in terminal cancer patients: a report from the national hospice study. J Chronic Dis 1986:39:32. 11. hag&i J, Rudriquez V, Rodey C. Causes !~f dcarlr in cancer patients. Callcer 1974:33:568-573.
