Assessing palliative care and healthcare resource utilization, and the role of chemoradiation in esophageal and gastric cancer

Patients with advanced esophageal and gastric cancer have a poor prognosis, and they often experience a high burden of symptoms impairing the quality of life. As a result, they frequently require comprehensive end-of-life care. Palliative care is an essential aspect of managing patients with advanced cancer, aiming to improve quality of life by addressing physical, emotional, and social needs. This dissertation consists of three retrospective cohort studies. Studies I and II evaluated the impact of palliative care decision and specialist palliative care on end-of-life healthcare utilization in adults with esophageal or gastric cancer. Study III focused on patients with esophageal cancer who received chemoradiation. In approximately half of patients with advanced esophageal or gastric cancer, the decision to transition to palliative care and terminate anticancer treatments—referred to as the palliative care decision—was made late or not at all. Only a small proportion of patients received specialist palliative care. We observed that early palliative care intervention, defined as palliative care decision or specialist palliative care contact, was associated with reduced hospitalizations and emergency department contacts in the last month of life. Furthermore, early palliative care decreased the likelihood of dying in a hospital setting. Palliative hospital-at-home care was associated with a higher probability of home death. We also found that in patients with esophageal cancer who received chemoradiation the overall clinical condition and cancer stage had a significant impact on treatment decisions, often leading to overtreatment. Patients with better prognoses were more likely to proceed to surgery after chemoradiation, despite no evidence from prior randomized trials of improved survival outcomes. Conversely, patients with advanced disease and poor general health had poor outcomes, even after definitive chemoradiation. Smoking was an independent prognostic factor for poorer survival, highlighting the importance of smoking cessation. This dissertation has elucidated the factors influencing treatment decisions and the use and impact of palliative care in the treatment of patients with advanced esophageal or gastric cancer. Early palliative care reduces healthcare utilization and improves access to specialist palliative care services, highlighting the importance of timely initiation of palliative care.