Underutilization of Palliative Care in Metastatic Foregut Cancer Patients Is Associated with Socioeconomic Disparities

BACKGROUND: Metastatic foregut cancers are frequently associated with debilitating symptoms that significantly impact patient's quality of life. Palliative care aims to mitigate disease-, psychosocial- and treatment-related effects. Despite numerous reported benefits and current guidelines and recommendations, palliative care remains heavily underutilized in patients with metastatic cancers. OBJECTIVE: Our aim was to determine the rate of palliative care utilization among patients with metastatic foregut neoplasms and determine the socioeconomic factors associated with receipt of palliative care. METHODS: A retrospective review of the National Cancer Database (NCDB) was conducted to identify patients diagnosed with metastatic foregut cancers between 2004-2013. The NCDB captures over 70% of all incident cancer cases in the United States. We identified patients with stage IV gastric, pancreatic, biliary, gallbladder and esophageal adenocarcinoma. Receipt of PC as defined by the NCDB participant use file was correlated to demographic and clinicopathologic factors. PC treatment included surgery, radiation, systemic therapy, and pain management to alleviate symptoms. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. RESULTS: Palliative care utilization rates increased among all groups over time (12.3% 2004-2006 vs. 14.7% 2007-2010 vs. 16.4% 2011-2013 for all cancers). Female sex, Medicaid, median income < USD 46,000/year, higher education level, higher Charlson/Deyo Score, and pancreatic or biliary cancers were associated with increased likelihood of palliative care interventions. Additionally, patients treated at an academic center or integrated network cancer program were more likely to receive palliative care than patients treated in the community setting. When receipt of palliative care was stratified by race, Hispanics were significantly less likely to have undergone palliative interventions compared to non-Hispanic Whites (OR 0.70, 95% CI 0.66-0.73). Patients with Medicare or private insurance were less likely to receive palliative care than uninsured patients (OR 0.92, 95% CI 0.87-0.97 and 0.81, 95% CI 0.77-0.89, respectively) CONCLUSION: Although PC use has increased over time, it remains significantly underutilized in MFC. Disparities exist in receipt of PC with regards to demographic and socioeconomic factors such as age, race, gender, insurance status, education, comorbidities and year of diagnosis. These identified factors can serve as targeted interventions aimed at increasing palliative care utilization. Additional research is necessary to better optimize PC use in metastatic cancers of the foregut and mitigate potential disparities.