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Address correspondence to: Cara L. McDermott, PharmD, PhD, Cambia Palliative Care Center of Excellence, University of Washington, HICOR, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-B232 Seattle, WA 98109.
Cambia Palliative Care Center of Excellence Department of Medicine, University of Washington, Seattle, Washington, USAHutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USADepartment of Pharmacy University of Washington, Seattle, Washington, USA
Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USADepartment of Pharmacy University of Washington, Seattle, Washington, USA
Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USADepartment of Pharmacy University of Washington, Seattle, Washington, USA
Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USADepartment of Pharmacy University of Washington, Seattle, Washington, USA
Limited data exist regarding how depression diagnosed at different times relative to a cancer diagnosis may affect healthcare utilization at end of life (EOL).
Objectives
To assess the relationship between depression and health care utilization at EOL among older adults (ages >=67) diagnosed with advanced non-small cell lung cancer (NSCLC) from 2009 to 2011.
Methods
Using the SEER-Medicare database, we fit multivariable logistic regression models to explore the association of depression with duration of hospice stay plus high-intensity care, for example inpatient admissions, in-hospital death, emergency department visits, and chemotherapy at EOL. We used a regression model to evaluate hospice enrollment, accounting for the competing risk of death.
Results
Among 13,827 subjects, pre-cancer depression was associated with hospice enrollment (sub-hazard ratio 1.19, 95% confidence interval [CI] 1.11–1.28), 90 + hospice days (adjusted odds ratio [aOR] 1.29, 95% CI 1.06–1.58), and lower odds of most utilization; we found no association with EOL chemotherapy. Diagnosis-time depression was associated with hospice enrollment (SHR 1.16, 95% CI 1.05–1.29) but not high-intensity utilization. Post-diagnosis depression was associated with lower hospice enrollment (SHR 0.80, 95% CI 0.74–0.85) and higher odds of ICU admission (aOR 1.18, 95% CI 1.01–1.37).
Conclusion
EOL healthcare utilization varied by timing of depression diagnosis. Those with pre-cancer depression had lower odds of high-intensity healthcare, were more likely to utilize hospice, and have longer hospice stays. Regular depression screening and treatment may help patients optimize decision-making for EOL care. Additionally, hospice providers may need additional resources to attend to mental health needs in this population.
Non-small cell lung cancer (NSCLC) is a highly lethal cancer that largely affects older adults, many of whom have multiple comorbidities and high symptom burden.
as depression is associated with both increased age and comorbidities. The presence of depression negatively affects quality of life for patients with lung cancer
High intensity end-of-life (EOL) care, such as hospitalization, emergency department (ED) visits, and chemotherapy use, is associated with poorer quality of life for cancer patients
Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries.
Planning the Transition to End-of-Life Care in Advanced Cancer (PDQ(R)): Health Professional Version. PDQ Cancer Information Summaries,
Bethesda (MD)2002
as an alternative to high-intensity healthcare, study findings have been mixed regarding the association between psychological distress and hospice enrollment.
Frequency of symptom distress and poor prognostic indicators in palliative cancer patients admitted to a tertiary palliative care unit, hospices, and acute care hospitals.
While depression may affect decision making, which in turn affects the quality of care received, no studies have explored the association between depression noted at different times relative to a cancer diagnosis and EOL healthcare utilization. While pre-cancer depression is not modifiable by clinicians, patients presenting with a history of depression have poorer functional status, more depressive episodes, and may have treatment-resistant depression, all of which negatively affects patient outcomes.
Knowing if depression that manifests at different times is associated with the intensity of EOL healthcare utilization can help with the timing of depression screening as well as potential interventions to maximize patients' decision-making capabilities in the face of life-limiting illness. Herein, we explored the association between pre-cancer, diagnosis-time, or post-diagnosis depression and EOL care received in a population-based sample of older adults with advanced NSCLC. We hypothesized that individuals with pre-cancer depression, given their longer history of distress and symptom burden, were least likely to use hospice and most likely to use high-intensity healthcare interventions at end of life.
Patients and Methods
Study Population
We used the SEER-Medicare database, comprised of Medicare claims linked to clinical data for subjects in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) dataset. The clinical records of 94% of subjects 65 and older in the SEER registries are connected to Medicare claims, with the demographic distribution in the database reflecting the population of older adults in the United States.
We included subjects age 67+ with NSCLC diagnoses from 2009 to 2011 and Medicare claims spanning 2007–2013. These inclusion criteria allowed for a look-back period of 24 months prior to NSCLC diagnosis to note depression claims and to evaluate Part D claims for oral chemotherapy.
To evaluate EOL decision-making within the timeframe of available claims, we limited our evaluation to subjects with metastatic (stage IIIB or IV) NSCLC diagnoses staged per American Joint Committee on Cancer (AJCC) sixth edition, given the limited life expectancy of this population. Staging histology codes appear in the Appendix. While guidelines recommend chemotherapy receipt in this population,
As we cannot review patient and clinician preferences in claims data, hospice is a reasonable choice given the limited life expectancy of this cohort, and our focus is EOL care, we evaluated time to hospice enrollment and hospice duration rather than receipt of chemotherapy, surgery or radiation. Additionally, as anti-cancer therapies affect survival following an advanced lung cancer diagnosis,
and we purposefully did not evaluate these therapies, we did not perform survival analyses.
We required that all subjects had continuous enrollment in fee-for-service Medicare parts A and B for at least 24 months prior to diagnosis to calculate a comorbidity score and evaluate for pre-cancer depression. We excluded patients diagnosed at autopsy or by death certificate and those diagnosed with other cancers or primary occult/unknown stage cancer. We also omitted subjects enrolled in a managed care plan, people who did not incur claims prior to their NSCLC diagnosis and people who qualified for Medicare based on end-stage renal disease. We eliminated records for subjects with claims for bipolar disorder or schizophrenia. We excluded subjects who did not die during the study observation period for our evaluation of inpatient admissions, intensive care unit (ICU) admissions, and ED visits in the last month of life, and chemotherapy receipt in the last 14 days of life. Our study criteria and resulting population appear in Figure 1. The Institutional Review Board of the Fred Hutchinson Cancer Research Center approved this study.
The goal of our analysis is to describe the association between depression, hospice use, and high-intensity healthcare utilization at end of life. Using previously published metrics, we defined high-intensity EOL care as chemotherapy in the last 14 days of life; less than 3 days of hospice use or no hospice use; any ICU admission, >1 hospitalization, in-hospital death, or >1 ED visit in the last 30 days of life.
We searched the inpatient, outpatient, carrier, and hospice claims files for hospitalization, ICU admission, in-hospital death (recorded as discharge status on claims), ED visits, and hospice use, with claim start dates used to calculate receipt of services relative to recorded death date. We searched for chemotherapy claims using Healthcare Common Procedure Coding System (HCPCS) for chemotherapy medications and administration in inpatient, outpatient, and durable medical equipment claims files, plus name search in Part D claims for oral chemotherapy or targeted therapies. We searched for systemic medications recommended for metastatic NSCLC per National Comprehensive Cancer Network guidelines available in 2012–2013, the last year of available claims.
We used a previously published algorithm that compared concordance between clinical diagnoses of depression and Medicare claims for older patients to identify patients with depression claims.
We looked for International Classification of Disease, version 9 (ICD-9) codes 296.2, 296.3, 298.0, 300.4, 309.0, 309.1, or 311 in inpatient, outpatient, and carrier claims files in the two years prior to and all claims after each patient's NSCLC diagnosis date. Additionally, we searched for any claims with the HCPCS codes G8431or G8511 indicating a positive depression screen, with or without documented treatment plan.
We categorized subjects into one of four categories: pre-cancer depression, diagnosis-time depression, post-diagnosis depression, or no depression. If a subject had a claim with an ICD-9 code or HCPCS code indicating depression in the 3 to 24 months preceding the NSCLC diagnosis, then we classified the subject as having pre-cancer depression. We characterized patients with a first depression code appearing in the 3 months preceding diagnosis to 30 days following diagnosis as having diagnosis-time depression,
as 3 months is a typical timeframe between symptom lead-time and an NSCLC diagnosis. We classified subjects with depression claims that first appeared more than 30 days after the NSCLC diagnosis date as having post-diagnosis depression.
The comparator group had no claims for depression at any time.
Covariates
Through a literature search, we identified factors that may affect EOL healthcare utilization and outcomes for patients with NSCLC and/or depression. As race,
Racial disparities in the use of hospice services according to geographic residence and socioeconomic status in an elderly cohort with nonsmall cell lung cancer.
have been identified as affecting healthcare utilization and patient outcomes, we controlled for these covariates in multivariable logistic regression models and competing risk regression. As many people with depression also experience anxiety,
we controlled for SEER registry, grouping registries as follows: West (San Francisco, San Jose, Los Angeles, Greater California, Hawaii, New Mexico, Seattle, Utah), Midwest (Detroit, Iowa), South (Atlanta, rural Georgia, Kentucky, Louisiana), and Northeast (Connecticut, New Jersey). For comorbidity calculations, we used the National Cancer Institute composite (Klabunde-Charlson) comorbidity index.
Subjects without any claims for depression comprised the control group.
Statistical Analyses
We calculated descriptive statistics for subjects with and without a history of depression with respect to age at diagnosis, gender, marital status, race, Hispanic ethnicity, comorbidity index, SEER registry, Medicaid eligibility, and urban residence.
To characterize the association between depression and hospice enrollment, we conducted a competing risk regression, accounting for the competing risk of death.
We included all subjects diagnosed with NSCLC, regardless of whether we observed the subject's death during the study period. We censored patients not observed to die by the end of the claims observation period of December 31, 2013. We describe duration of hospice enrollment, and constructed multivariable logistic regression models to determine the odds of very short hospice enrollment (<3 days) or lengthy hospice enrollment (longer than 90 days) by depression category.
To evaluate EOL healthcare utilization, we excluded subjects who did not die during the study period so we had the chance to observe the outcomes of interest. Among the remaining study population of decedents, we constructed multivariable logistic regression models to determine odds of in-hospital death, >1 ED visits, >1 hospitalizations, or ICU admission in the last 30 days of life, or chemotherapy receipt in the last 14 days of life. We controlled for days survived following diagnosis and demographic covariates. Initially, we included interaction terms for gender and age given the different incidence in depression by gender and age, however these were not in our final models as the interaction terms were not statistically significant.
We adjusted for the aforementioned covariates in all regression models and performed all analyses using Stata statistical software, version 15.1 (StataCorp, College Station, TX).
Sensitivity Analysis
We performed two sensitivity analyses. First, in our logistic regression models we excluded patients who did not survive 30 days following diagnosis to determine how the exclusion of such patients affected our results. Next, using a claims-based algorithm to identify subjects with a smoking history, we created a covariate to control for smoking in this cohort.
We included this covariate in our regression models to evaluate how attempting to control for smoking status in our analyses affected results, as smoking affects patient outcomes
but smoking status is not available in the SEER-Medicare database.
Results
Our overall study population is comprised of 13,827 people diagnosed with stage IIIB or IV NSCLC. Of those, 1485 (11%) are classified as having pre-cancer depression, 709 (5%) as having diagnosis-time depression, 1189 (9%) as having post-diagnosis depression and 10,444 (75%) as not having depression. Among 12,851 decedents, we classified 1378 (11%) of subjects with pre-cancer depression, 681 (5%) with diagnosis-time depression, 1055 (8%) with post-diagnosis depression, and 9737 (76%) as without depression. In both the overall study population and among decedents, subjects with pre-cancer depression or diagnosis-time depression are more likely to be female, unmarried, white, Medicaid-eligible, and have a higher co-morbidity score (Table 1, Table 2).
Table 1Demographics of 13,827 Subjects With Stage IIIB or IV Non–Small-Cell Lung Cancer, Categorized by Precancer Depression (Three to 24 Months Before Cancer Diagnosis), Diagnosis-Time Depression (Three Months Before to 30 Days After Cancer Diagnosis), Postdiagnosis Depression (31+ Days After Cancer Diagnosis), or No Depression Diagnosis at Any Time
SEER registries are categorized as follows: Northeast = Connecticut, New Jersey; Midwest = Detroit, Iowa; Southeast = Atlanta, Kentucky, Louisiana, greater and rural Georgia; West = greater California, Hawaii, Los Angeles, New Mexico, San Francisco, San Jose-Monterey, Seattle, Utah.
(n, %)
Northeast
262 (18%)
170 (24%)
299 (25%)
2024 (19%)
Midwest
219 (15%)
106 (15%)
155 (13%)
1355 (13%)
Southeast
451 (30%)
186 (26%)
289 (24%)
2800 (27%)
West
553 (37%)
247 (35%)
446 (38%)
4265 (41%)
a SEER registries are categorized as follows: Northeast = Connecticut, New Jersey; Midwest = Detroit, Iowa; Southeast = Atlanta, Kentucky, Louisiana, greater and rural Georgia; West = greater California, Hawaii, Los Angeles, New Mexico, San Francisco, San Jose-Monterey, Seattle, Utah.
Table 2Demographics of 12,851 Deceased Subjects With Stage IIIB or IV Non–Small-Cell Lung Cancer, Categorized by Precancer Depression (Three to 24 Months Before Cancer Diagnosis), Diagnosis-Time Depression (Three Months Before to 30 Days After Cancer Diagnosis), Postdiagnosis Depression (31+ Days After Cancer Diagnosis), or No Depression Diagnosis at Any Time
SEER registries are categorized as follows: Northeast = Connecticut, New Jersey; Midwest = Detroit, Iowa; Southeast = Atlanta, Kentucky, Louisiana, greater and rural Georgia; West = greater California, Hawaii, Los Angeles, New Mexico, San Francisco, San Jose-Monterey, Seattle, Utah.
(n, %)
Northeast
242 (18%)
166 (24%)
271 (26%)
1892 (19%)
Midwest
202 (15%)
102 (15%)
140 (13%)
1270 (13%)
Southeast
430 (31%)
178 (26%)
255 (24%)
2626 (27%)
West
502 (36%)
235 (35%)
389 (37%)
3949 (41%)
a SEER registries are categorized as follows: Northeast = Connecticut, New Jersey; Midwest = Detroit, Iowa; Southeast = Atlanta, Kentucky, Louisiana, greater and rural Georgia; West = greater California, Hawaii, Los Angeles, New Mexico, San Francisco, San Jose-Monterey, Seattle, Utah.
A majority of subjects, ranging from 58% to 66% across depression categories, utilized hospice after their cancer diagnosis (Table 3). Pre-cancer depression was significantly associated with 90+ days of hospice (adjusted odds ratio [aOR] 1.29, 95% confidence interval [CI] 1.06–1.58) but diagnosis-time or post-diagnosis depression were not associated with lengthy hospice stays. There was no significant association between any category of depression and very short hospice stays (<3 days). Accounting for the competing risk of death, subjects with pre-cancer depression had a 19% higher instantaneous hazard of hospice enrollment (sub-hazard ratio 1.19, 95% CI 1.11–1.28) as did those with diagnosis-time depression (SHR 1.16, 95% CI 1.05–1.29); those with post-diagnosis depression had significantly lower hospice enrollment (SHR 0.80, 95% CI 0.74–0.85).
Table 3Days of Hospice Enrollment Among 13,827 Subjects With Stage IIIB or IV Non–Small-Cell Lung Cancer, Categorized by Precancer Depression (Three to 24 Months Before Cancer Diagnosis), Diagnosis-Time Depression (Three Months Before to 30 Days After Cancer Diagnosis), Postdiagnosis Depression (31+ days After Cancer Diagnosis), or No Depression Diagnosis at Any Time
Multiple inpatient admissions were similar across groups, ranging from 11% to 15% across categories (Table 4). We found slightly lower odds of >1 inpatient admission for patients with pre-cancer depression (aOR 0.74, 95% CI 0.62–0.89) but no association for those with diagnosis-time depression (aOR 1.04, 95% CI 0.83–1.30) or for those with post-diagnosis depression (aOR 1.10, 95% CI 0.92–1.32). For reader reference, regression results are listed in Table 5.
Table 4End-of-Life Utilization Among 12,851 Decedents With Stage IIIB or IV Non–Small-Cell Lung Cancer, Categorized by Precancer Depression (Three to 24 Months Before Cancer Diagnosis), Diagnosis-Time Depression (Three Months Before to 30 Days After Cancer Diagnosis), Postdiagnosis Depression (31+ Days After Cancer Diagnosis) or No Depression Diagnosis at Any Time
N, %
Pre-cancer Depression (n = 1378)
Diagnosis-time Depression (n = 681)
Post-diagnosis Depression (n = 1055)
No Depression (n = 9737)
>1 inpatient admissions
158 (11%)
97 (14%)
160 (15%)
1320 (14%)
ICU admission
291 (21%)
154 (23%)
266 (25%)
2317 (24%)
In-hospital death
224 (16%)
133 (20%)
227 (22%)
2191 (23%)
>1 ED visits
96 (7%)
57 (8%)
100 (9%)
733 (8%)
Chemotherapy in last 14 days
150 (11%)
84 (12%)
123 (12%)
1189 (12%)
ICU = intensive care unit; ED = emergency department.
Table 5Results of Multivariable Logistic Regression for End-Of-life Utilization Outcomes Among 12,851 Decedents With Stage IIIB or IV Non-small Cell Lung Cancer, Categorized by Pre-cancer Depression (3–24 Months Before Cancer diagnosis), Diagnosis-time Depression (3 Months Before to 30 Days After Cancer diagnosis), Post-diagnosis Depression (31 + days After Cancer diagnosis) Compared to subjects With No Depression diagnosis at any Time
Odds of
Pre-cancer Depression
Diagnosis-time Depression
Post-diagnosis Depression
aOR (95% CI)
aOR (95% CI)
aOR (95% CI)
>1 inpatient admissions
0.74 (0.62–0.89)
1.04 (0.83–1.30)
1.10 (0.92–1.32)
ICU admission
0.78 (0.67–0.90)
0.90 (0.75–1.09)
1.18 (1.01–1.37)
In-hospital death
0.75 (0.64–0.87)
0.86 (0.70–1.04)
1.16 (0.99–1.36)
>1 ED visits
0.78 (0.62–0.98)
1.04 (0.78–1.38)
1.15 (0.92–1.45)
Chemotherapy in last 14 days
0.89 (0.74–1.07)
0.98 (0.78–1.25)
1.07 (0.87–1.31)
aOR = adjusted odds ratio; CI = confidence interval; ICU = intensive care unit; ED = emergency department.
ICU admissions were similar across groups, ranging from 21% to 25% (Table 4). We noted lower odds of ICU admission among those with pre-cancer depression (aOR 0.78, 95% CI 0.67–0.90), no association between ICU admission and diagnosis-time depression (aOR 0.90, 95% CI 0.75–1.09), and higher odds of ICU admission and post-diagnosis depression (aOR 1.18, 95% CI 1.01–1.37). Among those with pre-cancer depression, 16% had an in-hospital death compared to 20%–23% of other groups (Table 4). While we noted lower odds of in-hospital death (aOR 0.75, 95% CI 0.64–0.87) among those with pre-cancer depression, we found no association between diagnosis-time depression (aOR 0.86, 95% CI 0.70–1.04) or post-diagnosis depression (aOR 1.16, 95% CI 0.99–1.36) and in-hospital death.
In the last month of life, 7%–9% of subjects had >1 ED visit (Table 4). Pre-cancer depression was associated with lower odds of >1 ED visit in the last 30 days of life (aOR 0.78, 95% CI 0.62–0.98). We observed no association between diagnosis-time depression (aOR 1.04, 95% CI 0.78–1.38) or post-diagnosis depression (aOR 1.15, 95% CI 0.92–1.45) and >1 ED visit. Chemotherapy use in the last 14 days of life was similar across groups, at 11%–12%. We found no significant association between pre-cancer depression (aOR 0.89, 95% CI 0.74–1.07), diagnosis-time depression (aOR 0.98, 95% CI 0.78–1.25) or post-diagnosis depression (aOR 1.07, 95% CI 0.87–1.31) and chemotherapy receipt.
Sensitivity Analyses
In our first set of sensitivity analyses, we fit multivariable logistic regression models after excluding 9% of each group of pre-cancer depression, diagnosis-time depression, and non-depressed subjects (130, 86, and 931 people, respectively) who did not survive at least 30 days following diagnosis. By definition, subjects with post-diagnosis depression had to survive 30 days for categorization, thus were not included in this analysis. Most observed associations between pre-cancer depression, diagnosis-time depression and odds of inpatient admissions, ICU admission, in-hospital death, and chemotherapy use remained unchanged, but the association between pre-cancer depression and >1 ED visits was no longer significant (aOR 0.83, 95% CI 0.65–1.05).
Among 1378 decedents with pre-cancer depression, 894 (65%) were categorized as smokers, whereas 5936 (61%) of 9737 decedents without depression were categorized as smokers. A majority of decedents with diagnosis-time depression (424 of 681, 62%) or post-diagnosis depression (783 of 1,055, 74%) were also categorized as smokers. Our findings between depression and all outcomes were unchanged after including this covariate in our regression models.
Discussion
In an effort to understand how depression may affect healthcare intensity at end of life, we evaluated the association between depression measured at various times before, during, and after a cancer diagnosis on the intensity of end-of-life cancer care delivery among older adults with advanced NSCLC. Patients with pre-cancer and diagnosis-time depression had higher enrollment in hospice, and those with pre-cancer depression had significantly longer hospice stays. Pre-cancer depression is associated with lower odds of >1 hospitalization, ICU admission, in-hospital death, and multiple ED visits in the last 30 days of life but is not associated with chemotherapy use. Diagnosis-time depression was significantly associated with increased hospice enrollment while post-diagnosis depression was associated with higher odds of ICU admission and lower odds of hospice enrollment.
Our findings that pre-cancer depression is associated with lower-intensity EOL care have potential implications for practice. Specifically, further investigation into the reasons why those with pre-cancer depression receive lower-intensity care may help identify barriers to higher quality care, and inform ways to improve EOL care for cancer patients. It is possible that patients with pre-cancer and diagnosis-time depression were more likely to enroll in hospice as the result of referral patterns to hospice or palliative care services given the presence of depression and other comorbidities, especially given our finding that those with pre-cancer depression had significantly higher odds of 90 + hospice days. Subjects with pre-cancer and diagnosis-time depression had higher comorbidity scores, reflecting more illness. In previous studies, depression or distress was the second-most frequent reason for hospice referral among cancer patients, after uncontrolled pain.
those in our pre-cancer depression cohort may have received expedited referrals to palliative or hospice care. Such contact may in turn facilitate hospice entry, as physician factors and EOL care discussions are a significant factor predicting hospice enrollment.
most subjects utilized at least one form of high-intensity EOL care. Subjects with pre-cancer depression had lower odds of >1 inpatient admissions, ICU admission, >1 ED visits, and in-hospital death. Those with diagnosis-time depression had no association with any high-intensity outcomes, but those with post-diagnosis depression had higher odds of ICU admission. Our findings regarding pre-cancer depression are similar to those of Doan and colleagues,
who evaluated pre-cancer and post-cancer depression across multiple cancer types and stages at diagnosis in SEER-Medicare. Our findings regarding post-diagnosis depression differ, in that we note an association with higher utilization of ICU admission and lower hospice enrollment. A previous study found an inverse relationship between interventions, ICU use and hospice enrollment among metastatic NSCLC patients,
similar to our findings. Overall, our mixed findings recall those of a randomized trial of early palliative care in lung cancer, where depression and anxiety at baseline were associated with intravenous chemotherapy use at EOL but not hospitalization or emergency room use.
We categorized 11% of older adults as having pre-cancer depression, a percentage similar to other studies using SEER-Medicare. Those studies reported percentages of pre-cancer depression ranging from 5% in prostate cancer patients
While our claims-based analysis aligns with previous studies, our estimate is likely an under-estimate of depression in this population, as other studies have found depression prevalence ranging from 14%
among older adults with cancer. In our study population, those with pre-cancer depression were more likely to be female, Medicaid-eligible, white, and not married, similar to the demographics of depressed patients in a prospective observational study of lung cancer patients.
There are multiple limitations to this study. We used a retrospective cohort of decedents for high-intensity outcomes, comprised of sicker patients compared to those who lived beyond the end of the study observation period. While this introduces selection bias, a previous study has noted that prospective and retrospective analyses of EOL outcomes can produce similar results.
but as this is a claims-based analysis, we did not have access to information regarding preferences for care, availability of caregiver support, or advance care planning. We did not have access to the results of any screening depression tests (e.g. the Geriatric Depression Scale) or patient response to antidepressant therapy to help confirm our classification of subjects as depressed or not depressed. Subjects may be misclassified if a depressive episode occurred before the two-year look back period of this study. While performance status is associated with depression
this study contributes information regarding the timing of a depression diagnosis, specifically pre-cancer depression, diagnosis-time depression and post-diagnosis depression, and association on healthcare utilization in the last month of life. For oncology and palliative care clinicians, screening for and treating depression following a cancer diagnosis can help assure that patient decision-making capacity is optimal to express their wishes and thus receive goal-concordant EOL care. Our finding that pre-cancer depression is associated with higher enrollment and longer stays in hospice care indicates that hospice organizations may need to additional support to meet the mental health needs of their older enrollees with advanced NSCLC. Finally, future research to elucidate the underlying mechanisms for our observed association between pre-cancer depression and lower-intensity EOL care may help inform ways to facilitate high-quality EOL care for all cancer patients, regardless of depression diagnosis.
Disclosures and Acknowledgments
Thank you to Catherine Fedorenko, MMSci, and Stuart Greenlee for preparing data for analysis. This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.
The authors have no conflicts of interest to report.
Funding: This work was supported by the National Institutes of Health's National Heart, Lung, and Blood Institute Grant No. T32 HL125195–02 (C.L.M.).
Appendix
International Classification of Disease, Oncology (ICD-O) histology codes used to define non-small cell lung cancer:
Tabled
1
Code
Description
8010/3
Carcinoma
8012/3
Large cell carcinoma
8020/3
Carcinoma, undifferentiated, NOS
8022/3
Pleomorphic carcinoma
8031/3
Giant cell carcinoma
8032/3
Spindle cell carcinoma, NOS
8033/3
Pseudosarcomatous carcinoma
8046/3
Non-small cell carcinoma
8050/3
Papillary carcinoma, NOS
8052/3
Squamous cell papilloma, NOS
8070/3
Squamous cell carcinoma, NOS
8071/3
Squamous cell carcinoma, keratinizing, NOS
8072/3
Squamous cell carcinoma, large cell, nonkeratinizing, NOS
8073/3
Squamous cell carcinoma, small cell, nonkeratinizing
Generic names of systemic agents used for determination of chemotherapy/targeted agent receipt:
Tabled
1
Afatinib
Docetaxel
Mitomycin
Albumin-bound paclitaxel
Erlotinib
Paclitaxel
Bevacizumab
Etoposide
Pemetrexed
Carboplatin
Gemcitabine
Trastuzumab
Cetuximab
Gefitinib
Vinorelbine
Cisplatin
Ifosfamide
Vinblastine
Crizotinib
Irinotecan
We also utilized following Healthcare Common Procedure Coding System (HCPCS) indicating chemotherapy administration or agents: J8999, J9999, V5811, V662, V667.
Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries.
Planning the Transition to End-of-Life Care in Advanced Cancer (PDQ(R)): Health Professional Version. PDQ Cancer Information Summaries,
Bethesda (MD)2002
Frequency of symptom distress and poor prognostic indicators in palliative cancer patients admitted to a tertiary palliative care unit, hospices, and acute care hospitals.
Racial disparities in the use of hospice services according to geographic residence and socioeconomic status in an elderly cohort with nonsmall cell lung cancer.
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