Prostate cancer (PCa) is the most common noncutaneous cancer and the second leading cause of cancer-related death in North American men.1 In the United States, 233,000 new cases of PCa are estimated to be diagnosed in 2014, along with 29,480 PCa-related deaths.1 Several patients with terminal metastatic PCa are confronted with difficult choices at both ends of the spectrum, ranging from aggressive end-of-the-line anticancer therapy to hospice care.
End-of-life (EOL) care represents a challenge for both the patient and the physician. The physician-patient, through honest and empathic communication, must decide when high-intensity care is no longer beneficial and when the goals of care shift to focus on continued intense symptom management and quality EOL care. Continued high-intensity care, including intensive care unit (ICU) admissions, emergency department (ED) visits, acute-care hospital visits, and use of new anticancer therapies very close to death, lead to unpropitious physical, psychological, and monetary effects at EOL.2–7
Despite the well-established disparities in quality of PCa care between white and black patients,8–12 how this relationship applies to EOL care in the context of advanced PCa is unclear. Qualitative research, across multiple cancers, suggests the existence of such disparities between white and black patients at EOL, with prior studies showing that black patients with end-stage cancers are at increased risk for receiving high-intensity EOL care relative to white patients.8–12 It has been hypothesized that this may be due to to the lack of awareness among black patients about palliative and hospice care, the prohibitive cost of care, a mistrust of the system, and poor physician-patient communication.13–17
However, none of these studies focused specifically on advanced PCa, which is usually known to be more frequent in black men.18 To address this void, we sought to examine the impact of race on the use of EOL resources, with emphasis on the use of high-intensity care among patients with PCa during the last year of life.
Dr. Abdollah is a consultant for GenomeDx biosciences. Dr. Nguyen is a consultant for Ferring and Medivation. Dr. Kibel is a consult for Sanofi-Aventis, Dendreon, and Myriad. Dr. Trinh is supported by the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at the Brigham and Women's Hospital. The remaining authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
EarleCCNevilleBALandrumMB. Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care2005;17:505–509.
EarleCCParkERLaiB. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol2003;21:1133–1138.
BlechmanJARizkNStevensMMPeriyakoilVS. Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life. J Palliat Med2013;16:1285–1289.
TangemanJCRudraCBKerrCWGrantPC. A hospice-hospital partnership: reducing hospitalization costs and 30-day readmissions among seriously ill adults. J Palliat Med2014;17:1005–1010.
TemelJSGreerJAMuzikanskyA. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med2010;363:733–742.
WrightAAZhangBRayA. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA2008;300:1665–1673.
MiesfeldtSMurrayKLucasL. Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J Palliat Med2012;15:548–554.
LoggersETMaciejewskiPKPaulkE. Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol2009;27:5559–5564.
SmithAKEarleCCMcCarthyEP. Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc2009;57:153–158.
RosenfeldPDennisJHanenS. Are there racial differences in attitudes toward hospice care? A study of hospice-eligible patients at the Visiting Nurse Service of New York. Am J Hosp Palliat Care2007;24:408–416.
MahalBAZiehrDRAizerAA. Getting back to equal: the influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer. Urol Oncol2014;32:1285–1291.
MackJWPaulkMEViswanathKPrigersonHG. Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med2010;170:1533–1540.
BornWGreinerKASylviaE. Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos. J Palliat Med2004;7:247–256.
GainesARTurnerELMoormanPG. The association between race and prostate cancer risk on initial biopsy in an equal access, multiethnic cohort. Cancer Causes Control2014;25:1029–1035.
WarrenJLKlabundeCNSchragD. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care2002;40(8 Suppl):IV-3–18.
WongYNMitraNHudesG. Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA2006;296:2683–2693.
KlabundeCNPotoskyALLeglerJMWarrenJL. Development of a comorbidity index using physician claims data. J Clin Epidemiol2000;53:1258–1267.
ConnorSRPyensonBFitchK. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage2007;33:238–246.
BlairIVHavranekEPPriceDW. Assessment of biases against Latinos and African Americans among primary care providers and community members. Am J Public Health. 2013;103:92–98.
HargravesJLCunninghamPJHughesRG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res2001;36:853–868.
ShiLChenCCNieXZhuJHuR. Racial and socioeconomic disparities in access to primary care among people with chronic conditions. J Am Board Fam Med2014;27:189–198.
YasaitisLCBynumJPSkinnerJS. Association between physician supply, local practice norms, and outpatient visit rates. Med Care2013;51:524–531.
HanBRemsburgREIwashynaTJ. Differences in hospice use between black and white patients during the period 1992 through 2000. Med Care2006;44:731–737.
TenoJMGozaloPLBynumJP. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA2013;309;470–477.
FishmanJO'DwyerPLuHL. Race, treatment preferences, and hospice enrollment: eligibility criteria may exclude patients with the greatest needs for care. Cancer2009;115:689–697.
JohnsonKSKuchibhatlaMTulskyJA. What explains racial differences in the use of advance directives and attitudes toward hospice care?J Am Geriatr Soc2008;56:1953–1958.
FishmanJMTen HaveTCasarettD. Is public communication about end-of-life care helping to inform all? Cancer news coverage in African American versus mainstream media. Cancer2012;118:2157–2162.
RhodesRLBatchelorKLeeSCHalmEA. Barriers to end-of-life care for African Americans from the providers' perspective: opportunity for intervention development. Am J Hosp Palliat Care2015;32:137–143.