Hospice Use Less Common for Minority Women With Ovarian Cancer

A new study finds that women with ovarian cancer who were black or Hispanic tended to undergo more aggressive treatment and were less likely to receive hospice services at the end of life.

A number of factors have been shown to influence the likelihood of a terminally ill patient using hospice care, such as obesity or veteran status, but the research recently published in the Journal of Clinical Oncology indicates that one’s race or ethnicity also contributes to the type of end-of-life care received.

Researchers gathered a sample of 3666 women in Texas aged 66 or older who died of ovarian cancer between 2000 and 2012. Their main outcome variables included hospice enrollment, death while in hospice, chemotherapy in the final 2 weeks of life, multiple emergency department visits or hospital admissions in the final month of life, intensive care unit (ICU) admission in the final month, and receiving an invasive or life-extending procedure in the final month of life.

Nearly three-quarters (72%) of the study group were enrolled in hospice before they died, but just 64% actually died in hospice, as 11% of the hospice enrollees unenrolled sometime before death. The most common care outcome in the final 30 days of life was receiving an invasive procedure (23%), while 16% of patients were admitted to the ICU and 14% were admitted to the hospital more than once.

The researchers found several disparities in end-of-life outcomes by racial or ethnic minority status, even after controlling for factors like poverty, educational attainment, comorbidities, and geographic category of residence. For instance, white patients were significantly more likely to both enroll and die in hospice than those who were Hispanic or black. Patients of other or unknown race were more likely to go into hospice as an inpatient or during the last 3 days of life.

There were also significant racial or ethnic differences in hospital admissions and aggressive treatments given at the end of life. In the final month of life, Hispanic patients were more commonly admitted to the ICU, while black patients were more likely to have multiple emergency visits. Black women also had higher odds of undergoing a life-extending procedure, such as intubation, cardiopulmonary resuscitation, or placement of a feeding tube, in the final 30 days of their life.

Finally, the study authors analyzed the likelihood of intensive treatment based on secondary variables. Women living in census tracts with a high percentage of poverty were less likely to be admitted to the ICU in the final 30 days of life, while women in urban areas were significantly more likely to have an ICU admission, undergo a life-extending procedure, or receive an invasive procedure than women in rural areas.

These findings, according to the authors, “suggest that important disparities in use of end-of-life care persist among racial and ethnic minorities,” especially as they are more likely to experience the intensive care and hospital admissions that most oncology guidelines suggest should be avoided at the end of life. On the other hand, white women were more likely to enroll in hospice before death, which is recommended because “avoiding invasive care and focusing on more palliative goals near the end of life can not only avoid physical discomfort but also potentially bring greater satisfaction to patients and family members.”

The researchers noted that their study could not identify the causes of these disparities, but they acknowledged the “definite need for continued evaluation and performance improvement” in the area of end-of-life care.

“Importantly, it has yet to be established from the perspective of a patient with ovarian cancer what type of care is valued at the end of life and how these perspectives may or may not vary by race and ethnicity,” they concluded.