Adding palliative care consultation to standard care for patients who have a serious illness can reduce hospitalization costs significantly, according to researchers from The Palliative Care Leadership Centers' Outcomes Group. The group's analysis appeared yesterday in the Archives of Internal Medicine and showed an adjusted net savings of $279 per day for palliative care patients who were discharged alive and a savings of $374 per day for patients who received palliative care consultation but died during their hospital stay. Such consultations outline a patient's treatment priorities and can help avoid unnecessary tests or treatment that might otherwise be used to prolong life at any cost.
This retrospective, nonrandomized study focused on patient records from 2002 to 2004 at eight hospitals around the United States, representing low-, medium-, and high-cost markets. All hospitals employed experienced palliative care consultation teams, and the use of palliative care and related costs were identified by billing codes. The analysis matched 2,630 palliative care patients with 18,427 usual-care patients who were discharged alive, and 2,278 palliative care patients who died in the hospital were matched with 2,124 usual-care patients who died in the hospital.
The researchers found that palliative care consultation saved $1,696 per patient admitted if the patient survived, mostly attributed to lower laboratory costs ($424 per admission) and lower ICU costs ($5,178 per admission). The savings per admission for palliative care patients who died in the hospital were $4,908. Length of stay in the hospital ranged from 7 to 30 days.
"Our data suggest that palliative care consultation fundamentally shifts the course of care…," the authors write, "and in doing so, significantly reduces costs. This shift is likely accomplished by establishing clear treatment goals, reviewing current treatments to establish their concordance with these goals, and recommending and legitimizing discontinuation of treatments or tests that do not meet established goals."
More Treatments for Cancer-Related Fatigue Needed
Cancer-related fatigue commonly affects patients both during and after treatment. In a systematic review of pharmacologic treatments for cancer-related fatigue, investigators from St. George's University of London found that the psychostimulant methylphenidate provided a small but significant reduction in fatigue compared with placebo in two studies of 264 patients. In addition, the hematopoietic growth factor erythropoietin provided a clinically significant reduction in fatigue in 10 studies of 2,226 anemic patients undergoing chemotherapy, although the doses given and duration of treatment varied widely between trials. The study appeared in the August 20 Journal of the National Cancer Institute.
The investigators searched the Cochrane, Medline, and EMBASE databases of medical literature, and performed additional searches of selected journals and reference lists from identified articles. They found 27 randomized controlled trials, with a total of 6,746 participants, that tested a drug against placebo or standard care, aimed to improve quality of life, and robustly measured fatigue.
The review also included trials that tested darbepoetin, the antidepressant paroxetine, and progestational steroids. None of these drugs had a statistically significant effect on fatigue, though there was a borderline significant reduction with the use of darbepoetin in anemic patients.
Overall, the effects of both methylphenidate and erythropoietin were small, and both drugs have drawbacks, explain the authors. Methylphenidate is potentially addictive, and research has not identified which patients are most likely to benefit from treatment. Recent studies have raised safety concerns about erythropoietin.
"Future research into cancer-related fatigue…should not focus simply on the role of drugs," conclude the authors. Exercise and psychological techniques such as cognitive behavioral therapy may potentially help with fatigue, but need to be tested in adequately designed clinical trials.
In addition, explain the authors, "Many potential mechanisms and contributing factors could cause or increase the level of cancer-related fatigue…if mechanisms that produce fatigue could be identified, it may also be possible to design more targeted drug therapies or other interventions."
Evidence-Based Standards Developed for Pain Control
An expert panel of nine researchers from academic and community settings has published key standards and recommendations for cancer pain management. Development of the standards, published in the August 10 Journal of Clinical Oncology, involved a systematic literature review and deliberations by the expert panel, which rated each recommendation on validity and feasibility.
For general pain management, Dr. Sydney M. Dy of The Johns Hopkins University and his colleagues, recommend routine screening, descriptive pain assessment for etiology and functional impairment, routine pain education, and follow-up of pain management. For most metastatic bone pain, single-fraction radiation treatment is as effective as multiple treatments, they say, and should be offered whenever clinically possible. For back pain and spinal compression, the authors recommend quick treatment with corticosteroids, imaging with whole-spine MRI or myelography, and starting definitive treatment - such as radiotherapy or surgical decompression - within 24 hours.
The recommendations also address the common side effects that often arise in patients receiving chronic or long-acting opioids for pain, such as morphine, oxycodone, and fentanyl. These patients, the authors write, should receive bowel regimens to counter constipation; their dosage should be carefully monitored when they switch treatment settings; and they should receive breakthrough pain medications as needed.
"Pain is one of the most common...symptoms in cancer," the authors write. "These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes."
Math Model Projects Health and Economic Effects of HPV Vaccine
The effect of HPV vaccination on cervical cancer outcomes in the United States won't become evident for many years. In the meantime, to address questions about who should receive the vaccine, researchers from the Harvard School of Public Health have used a mathematical model to project the cost-effectiveness of vaccinating 12-year-old girls, as well as vaccinating older girls and women up to the age of 26. Their analysis appeared August 21 in the New England Journal of Medicine.
The authors' calculations were built on a model of male and female sexual behavior over time, as well as the carcinogenic effects of the virus in cervical tissue. It accounted for both forms of the vaccine that are currently used in clinical practice, the effect of waning immunity after vaccination with and without boosters, and possible protection against strains other than HPV type 16 and 18 that aren't part of the current vaccine formula.
Assuming lifelong immunity, their calculation showed that routine vaccination of 12-year-old girls, in addition to routine cervical screening, costs $43,600 per quality-adjusted life year (QALY) gained, above the cost of screening alone. For girls aged 13 to 18 years, the cost was $97,300 per QALY. Extending vaccination to women aged 21 cost $120,400 per QALY, and up to 26 years of age, the cost was $152,700 per QALY.
In projections where the vaccine protected against HPV types 6 and 11, which cause genital warts, the costs were reduced by 13 to 20 percent. (The reductions diminished as age increased.) However, factors that increased the cost per QALY for all age groups included immunity lasting only 10 years, thus requiring a booster, and a scenario in which 5 percent of the female population aged 26 and younger did not get screened or vaccinated. Frequency of screening and testing protocols also affected the cost, which could go as high as $200,000 per QALY.
The cost-effectiveness of HPV vaccination in the United States will depend on the duration of vaccine immunity and "will likely be optimized by achieving universal coverage in young adolescent girls and targeting initial catch-up efforts to girls and women younger than 21 years of age," the researchers conclude.
Phase III Trial of Immunotherapy for Prostate Cancer Stopped
A phase III clinical trial testing a prostate cancer immunotherapy treatment in men with advanced, hormone-refractory prostate cancer (HRPC) has been halted because of a greater number of deaths in patients receiving the investigational treatment. The company that developed the treatment, Cell Genesys, announced the trial's termination following a recommendation made by its Independent Data Monitoring Committee (IDMC).
Men in the trial, dubbed VITAL-2, were randomly assigned to either the combination of an investigational immunotherapy treatment called GVAX and the chemotherapy drug docetaxel or the combination of docetaxel and the corticosteroid prednisone. More than 400 patients were enrolled in the trial, and at the time of its analysis, 114 deaths had occurred, 67 in the GVAX arm and 47 in the docetaxel/prednisone arm.
"A specific cause for the imbalance in deaths has not been identified," Cell Genesys said in a statement. "The Company plans to fully analyze the clinical data from these patients to attempt to understand the potential cause for the higher rate of deaths observed in the GVAX arm."
A second phase III trial of GVAX, called VITAL-1, is evaluating GVAX as a monotherapy in earlier stage HRPC patients with metastatic disease. Its IDMC has not recommended halting the trial. The company has asked the committee, however, to conduct a "futility analysis" of VITAL-1 to determine whether the trial is likely to achieve its primary endpoint of improved survival in the GVAX arm.