Despite possible concerns about its quality, receiving palliative care and dying at home did not have a detrimental effect on the survival of end-stage cancer patients, according to results of a Japanese multicenter study.

Patients who died at home had significantly longer survival in unadjusted models (HR 0.86, 95% CI 0.78-0.96, P<0.01) and in models adjusted for age (per decade), sex, primary cancer site, presence of metastasis, anticancer therapy within 1 month, presence of delirium, and palliative performance scale category (HR 0.87, 95% CI 0.77-0.97; P=0.01), reported Jun Hamano MD, of the University of Tsukuba in Japan, and colleagues.

Dying at home significantly enhanced survival of patients in their last weeks or days of life compared with those who died in hospital, they wrote in Cancer.

"The most important finding of this study is that patients who died at home had a survival time similar to or significantly longer than that of patients who died in a hospital, after adjustments for background factors with the proven prognostic classification Prognosis in Palliative Care Study model A (PiPS-A)," the authors wrote.

Previous research has shown that place of death does affect the quality of end of life experience, and that more than 50% of people would prefer to be cared for and die at home.

Despite this preference, death at home is not achieved in many countries or is achieved only at a very late stage of the disease, often due to lack of caregivers and/or resources, or because of concerns that survival may be shortened because of less effective medical care at-home compared to in-hospital, the authors noted.



Hamano told MedPage Today that "while we don't have any data as to whether the quality of those extra days at end of life was better at home than in hospital, I think both patient and family could be more comfortable at home."

The study corroborated findings of a preliminary single-center study showed that patients receiving home-based palliative care had a median survival time of 67 days significantly longer than the 33 days observed with hospital-based palliative care. However, the study was limited by lack of adjustment for sufficient prognostic factors.

Hamano and colleagues analyzed data analysis from 2,069 cancer patients in the care of 58 participating palliative care services from September 2012 to April 2014. Most were referred for symptom control (pain, delirium, and dyspnea) and care during dying.

Eligible patients had a mean age of 69.4, and had locally advanced or metastatic cancer (including hematopoietic neoplasms). The most frequent site of primary cancer was gastrointestinal tract, followed by respiratory tract/intrathoracic cancer. Patients dying at long-term care facilities were excluded.

To adjust for patient factors that might affect survival, the investigators classified patients according to the modified PiPS-A survival groups: patients surviving for days (0-13 days), weeks (14-55 days), and months (>55 days). Survival time was measured from the day of referral to the date of death, up to 180 days, after which time survivors were censored.

Of the 1,582 patients receiving care in hospital and 487 receiving care at home, a total of 1,607 patients died in hospital, and 462 patients died at home.

A significantly longer survival time was seen among patients who died at home versus those who died in hospital with an estimated median survival time of 13 days (95% CI 10.3-15.7 days) versus 9 days (95% CI 8.0-10.0 days, P=0.006) in the days' prognosis group, and 36 days (95% CI 29.9-42.1 days) versus 29 days (95% CI, 26.5-31.5 days, P=0.007) in the weeks' prognosis group. No significant difference was seen in the months' prognosis group.

Survival time was significantly influenced by age (per decade), sex, palliative performance scale category, lung cancer, gastrointestinal cancer, breast cancer, delirium, and modified PiPS-A group.

The study also compared survival effects related to life-sustaining treatment -- parenteral hydration during the 48-72 hours before death and antibiotic therapy during the initial 3-week period after enrollment -- that was used in a significantly higher percentage of patients dying in hospital.

Home-based care was associated with extended survival, although this effect was significant only in the PiPS-A days' prognosis group (P=0.039). The authors noted that the survival benefit seen despite less use of life-sustaining treatment could indicate that these treatments were not effective for prolonging survival in this patient population.

Study limitations included data lost to follow-up on 63 participants, and potential selection biases in terms of the characteristics of patients referred for palliation at home versus hospital.

Stephanie Blank, MD, of NYU Langone Medical Center in New York City noted that U.S. home- and hospital-based hospice care are likely to differ from Japan's care.

But she pointed out that "this research highlights the importance of listening to patients and not assuming more medical care is necessarily better."

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