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.
Earle CC, Neville BA, Landrum MB. Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care 2005;17:505–509.
Earle CC, Park ER, Lai B. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;21:1133–1138.
Blechman JA, Rizk N, Stevens MM, Periyakoil VS. Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life. J Palliat Med 2013;16:1285–1289.
Tangeman JC, Rudra CB, Kerr CW, Grant PC. A hospice-hospital partnership: reducing hospitalization costs and 30-day readmissions among seriously ill adults. J Palliat Med 2014;17:1005–1010.
Temel JS, Greer JA, Muzikansky A. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733–742.
Wright AA, Zhang B, Ray A. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–1673.
Miesfeldt S, Murray K, Lucas L. Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J Palliat Med 2012;15:548–554.
Loggers ET, Maciejewski PK, Paulk E. Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol 2009;27:5559–5564.
Smith AK, Earle CC, McCarthy EP. Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc 2009;57:153–158.
Bergman J, Saigal CS, Lorenz KA. Hospice use and high-intensity care in men dying of prostate cancer. Arch Intern Med 2011;171:204–210.
Earle CC, Neville BA, Landrum MB. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 2004;22:315–321.
Rosenfeld P, Dennis J, Hanen S. 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 Care 2007;24:408–416.
Mahal BA, Ziehr DR, Aizer AA. 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 Oncol 2014;32:1285–1291.
Mack JW, Paulk ME, Viswanath K, Prigerson HG. Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med 2010;170:1533–1540.
Born W, Greiner KA, Sylvia E. Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos. J Palliat Med 2004;7:247–256.
Gaines AR, Turner EL, Moorman PG. The association between race and prostate cancer risk on initial biopsy in an equal access, multiethnic cohort. Cancer Causes Control 2014;25:1029–1035.
Warren JL, Klabunde CN, Schrag D. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 2002;40(8 Suppl):IV-3–18.
Wong YN, Mitra N, Hudes G. Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA 2006;296:2683–2693.
Klabunde CN, Potosky AL, Legler JM, Warren JL. Development of a comorbidity index using physician claims data. J Clin Epidemiol 2000;53:1258–1267.
Connor SR, Pyenson B, Fitch K. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007;33:238–246.
Saito AM, Landrum MB, Neville BA. Hospice care and survival among elderly patients with lung cancer. J Palliat Med 2011;14:929–939.
Blair IV, Havranek EP, Price DW. Assessment of biases against Latinos and African Americans among primary care providers and community members. Am J Public Health. 2013;103:92–98.
Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 2001;36:853–868.
Shi L, Chen CC, Nie X, Zhu J, Hu R. Racial and socioeconomic disparities in access to primary care among people with chronic conditions. J Am Board Fam Med 2014;27:189–198.
Yasaitis LC, Bynum JP, Skinner JS. Association between physician supply, local practice norms, and outpatient visit rates. Med Care 2013;51:524–531.
Han B, Remsburg RE, Iwashyna TJ. Differences in hospice use between black and white patients during the period 1992 through 2000. Med Care 2006;44:731–737.
Teno JM, Gozalo PL, Bynum JP. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013;309;470–477.
Fishman J, O'Dwyer P, Lu HL. Race, treatment preferences, and hospice enrollment: eligibility criteria may exclude patients with the greatest needs for care. Cancer 2009;115:689–697.
Johnson KS, Kuchibhatla M, Tulsky JA. What explains racial differences in the use of advance directives and attitudes toward hospice care? J Am Geriatr Soc 2008;56:1953–1958.
Fishman JM, Ten Have T, Casarett D. Is public communication about end-of-life care helping to inform all? Cancer news coverage in African American versus mainstream media. Cancer 2012;118:2157–2162.
Rhodes RL, Batchelor K, Lee SC, Halm EA. Barriers to end-of-life care for African Americans from the providers' perspective: opportunity for intervention development. Am J Hosp Palliat Care 2015;32:137–143.