Elderly US Nursing Home Residents Whose Care Is Funded By Medicaid Receive Limited Cancer Care

Elderly nursing home residents whose care is funded by Medicaid, a state-administered scheme in the US that pays for healthcare for people with low incomes, receive limited cancer services, with only a small proportion undergoing surgery, chemotherapy or radiotherapy, warns a study.


Approximately one in 10 people living in elderly nursing homes have cancer, but very little research has previously looked at this group. Researchers, led by Cathy Bradley, from Virginia Commonwealth University in Richmond, Virginia, USA, used the Michigan Tumor Registry and Medicaid records to identify elderly nursing home residents diagnosed with cancer between 1 January 1997 and 31 December, 2000, and who were receiving state-funded care. They found 1907 patients and compared their cancer care with other Michigan residents living in the community who were diagnosed with cancer during the same period.


The results showed than nearly two-thirds (62%) of the Medicaid-insured nursing home residents diagnosed with cancer had late or unstaged disease - cancer for which not enough information is available to indicate the stage or severity, which is an important factor in guiding cancer management. The commonest cancers were colon/rectum (17%), lung (15%), breast (14%) and prostate (10%).


The researchers noted that late and unstaged cancer was far more common in nursing home patients than in older elderly cancer patients living in Michigan. This may be partly explained by their greater frailty, which previous research has shown may make cancer screening such as mammography more stressful, but they suggested: "It is also possible that nursing homes are challenged in their ability to provide day-to-day care. Therefore, cancer-related services may receive a low priority."


The study showed that the nursing home residents received limited treatment for their cancer. Only 22% had surgery related to their cancer, with the majority of this being for women with breast cancer. Fewer than one in ten (6%) received chemotherapy and/or radiation.


Cancer spread, age and race affected the likelihood of having surgery. Patients with local-stage disease were most likely to have surgery. Those who were younger (aged 71-75 years) were nearly three times more likely to have surgery for their cancer than older nursing home residents (86 years and older). African American patients were only half as likely to receive surgery compared to white patients.


Mortality was high, with nearly half of the nursing home residents (48%) dying within three months of being diagnosed with cancer. The average survival after diagnosis was only nine months. Only about one-quarter (28%) of people with distant-stage cancer received hospice care. The researchers considered this was low, particularly as hospice use can achieve appropriate pain management and increase satisfaction with end-of-life care.















Information on patient or family preferences for treatment was not available, Dr Bradley and her colleagues acknowledged, and their study looked only at Medicaid-funding nursing home residents in Michigan, so was not representative of all people living in nursing homes. But they concluded: "Very few cancer services are provided to Medicaid-insured nursing home patients, despite the fact that many of these patients likely experienced cancer-related symptoms and marked physical decline before diagnosis and death."


In an accompany editorial, Noreen Aziz and Keith Bellizzi, from the Office of Cancer Survivorship at the National Cancer Institute, commented: "The fact that Medicaid-insured nursing home patients ??¦ had a preponderance of late and unstaged disease, high mortality within a few months of diagnosis, low hospice utilization, and little cancer-directed treatment is of concern."


Looking at how the low level of cancer care for Medicaid-funding elderly nursing home residents could be improved, the study authors suggested: "Guidelines for the recognition and treatment of cancer in frail elderly patients are needed and should be communicated to health care professionals, patients and care givers."


Aziz and Bellizzi agreed that standards, guidelines or best practices for cancer care were needed, particularly in the elderly, adding: "It is time that we enhance efforts to achieve clarity regarding the experiences of cancer-related care in our elderly cancer survivors."


Absence of Cancer Diagnosis and Treatment in Elderly Medicaid-Insured Nursing Home Residents

Cathy J. Bradley, Jan P. Clement, Chunchieh Lin

J Natl Cancer Inst 2008, 100: 21-31


Older Survivors and Cancer Care

Noreen M. Aziz, Keith Bellizzi

J Natl Cancer Inst 2008 100: 4-5


Cancer Research Summaries are overviews of important cancer research findings that have been reported in leading cancer publications. The Cancer Research Summaries are provided by the Cancer Meda Service (CMS) in collaboration with Nature Clinical Practice Oncology.

This summary is provided by the Cancer Media Service which is operated by The European School of Oncology.


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