Follow-Up Study of Survival of Patients with Advanced Cancer in a Hospice Setting

In recent years, cardiovascular diseases and malignant tumors have become the leading causes of death in China (Cook and Dummer, 2004). The total mortality rate decreases by 9.33% between 1970s and 1990s, but malignant cancer mortality increases by 29.42% and thus cancer has been the second leading cause of death in China (Guo et al., 2012). It is the first and second leading cause of death for urban and rural residents, respectively (Chen, 2009). Obviously, cancer poses a big threat to human health. Although the development of health care has reached an unprecedented level, it appears to be inadequate in the treatment of cancer (Wang et al., 2012). Routine anti-tumor therapy has been difficult to further extend the survival time of patients with late stage cancer and improve their life qualities. In 1967, the English hospice experts Dr. Sicily Saunders introduced for the first time the hospice concept and strategy in clinical practice and brought benefits to the majority of advanced cancer patients. Today, hospice care is booming and widely accepted as an effective approach in the world (Morin et al., 2007; Smith et al., 2007; Henry, 2011). This study aimed to represent their living conditions by investigating the survival time, survival rate and influencing factors on advanced cancer patients who received hospice care.


Introduction
In recent years, cardiovascular diseases and malignant tumors have become the leading causes of death in China (Cook and Dummer, 2004).The total mortality rate decreases by 9.33% between 1970s and 1990s, but malignant cancer mortality increases by 29.42% and thus cancer has been the second leading cause of death in China (Guo et al., 2012).It is the first and second leading cause of death for urban and rural residents, respectively (Chen, 2009).Obviously, cancer poses a big threat to human health.Although the development of health care has reached an unprecedented level, it appears to be inadequate in the treatment of cancer (Wang et al., 2012).Routine anti-tumor therapy has been difficult to further extend the survival time of patients with late stage cancer and improve their life qualities.In 1967, the English hospice experts Dr. Sicily Saunders introduced for the first time the hospice concept and strategy in clinical practice and brought benefits to the majority of advanced cancer patients.Today, hospice care is booming and widely accepted as an effective approach in the world (Morin et al., 2007;Smith et al., 2007;Henry, 2011).
This study aimed to represent their living conditions by investigating the survival time, survival rate and influencing factors on advanced cancer patients who received hospice care.

Follow-Up Study of Survival of Patients with Advanced Cancer in a Hospice Setting
Yu-Mei Wang 1 *, Hai-Qiang Guo 2

Research Objects
Retrospective analysis and prospective follow-up investigation were performed on 674 cases of advanced cancer patients enrolled in a hospice from January 2007 to December 2009.The follow-up terminated on December 31, 2010.The malignant tumors of all cases were confirmed by pathology, clinical diagnosis or imaging diagnosis.Besides, all patients lived on basic living allowance as their economic source.

Follow-Up Survey and Scale
The medical records were checked to confirm their diagnosis of cancer and to understand their conditions since diagnosis.Follow-up of survival were then performed by telephone or visit and terminated when the patient died from the diagnosed cancer.Survival time was determined from the time of diagnosis to the point of death or follow-up termination.The data obtained from the case of non-cancer deaths, missing cases, and surviving cases when follow-up ended were treated as censored data in analysis.The degree of pain was assessed by numeric rating scale (NRS): 0 for painless, 1-3 for mild pain, 4-6 moderate pain, and 7-10 severe pain.The reliability and validity of this scale have been confirmed by a number of practices.The survey was performed by a special person and evaluation form was filled out in sequence.

Statistical Tools and Methods
SPSS 13.0 software was used to analyze the data.The product limit method was used to calculate survival rate and survival time.Log rank test was used in univariate analysis of factors that may have impact on survival time, while Cox' proportional hazard regression model was used in the multivariate analysis.Inspection level α was set as 0.05.

Analysis of general information
A total of 674 patients with late stage cancer were involved in the follow-up survey, including 376 (55.8%) male and 298 (44.2%) female with the male to female ratio of approximately 1.3:1.They were diagnosed at the age of 13 to 95 with average 58.30±13.531.Male patient's average diagnosis age was 57.58±12.914,and female 59.21±14.240.There was no significant difference in the age between gender as the statistical result was: Z=-1.554,P=-0.120.The number of patient who have no pain before treatment was 0, mild pain 69 (10.2%), moderate pain 24 (3.6%) and severe pain 577 (86.1%).The corresponding numbers after one week treatment were 2 (0.3%), 175 (27.3%), 20 (3.1%) and 443 (69.2%).The difference was significant as the statistical result was: Z=-6.705,P<0.001.Other general information and composition are shown in Table 1.

Survival analysis
Follow up survey resulted in 597 (88.6%) complete data and 77 (11.4%) censored data.Median survival time was calculated as 12.00 months and average 25.05 months for all patients died from diagnosed cancer.One year cumulative survival rate was determined as 0.518 in ± 0.020, 5-year cumulative survival rate 0.088 ± 0.012, and 10-year cumulative survival rate 0.027 ± 0.007.The survival function was shown in Figure 1 and the statistical results for all factors posing impact on survival time were listed in Table 2.
In addition to above factors, adverse reaction (especially nausea) and pain (especially visceral pain and bone pain) also had statistically significant impact on survival time.The Log Rank values were 4. 747, 19.206, 16.108, 9.755 and 13.058, respectively.All of the p-values were smaller than 0.05.Multivariate analysis was then carried out using Cox model on the significant factors.The χ 2 was 134.404, p<0.001, which meant that the model was statistically significant.The -2Log likelihood was 5232.370.The regression results for each variable were listed in Table 3.
As shown in Table 3, the partial regression coefficient of gender, primary tumor, surgery, duration of pain and diagnosis age were statistically significant, which further confirmed the impacts of these factors on survival time.

Discussion
General information: The results of this study showed that most advanced cancer patients were approximately 60 years old.There was no significant difference in onset age between genders.A large proportion of patients with digestive and respiratory system tumors were seen.Tumor metastases as well as poor nutritional status were common in the patients.
Survival rate: There was a rapid decline in the survival rate with time and the median survival time was only 1 year.It maybe results from the poor economic conditions and consequent delay in the diagnosis as well as treatment of cancer.Previous studies have shown that early stage lung cancer patients may benefit from surgery and adjuvant chemotherapy (Zheng et al, 2011).Early detection and treatment are the key to improve the survival rate of malignant tumor patients (Smith et al, 2006).In order to further improve the survival rate, public education is needed to promote the participation of patients and even the whole society in the diagnosis and treatment of cancer (Rhodes, 1995).
Survival Time: Our study showed that women had a longer survival time than men.The reason may be that men have more physical exertion and also are more exposed to various pressures, suggesting that men should pay more attention to early detection.Age was also significantly related with survival time.That's possibly because immunity declines with age, suggesting that older people should pay attention to enhance their immunity and get treatment timely when pain occurs.Digestive and respiratory system cancers usually result in a shorter survival time.The sooner the pain occurs, the longer the survival time lasts, indicating that people sensitive to symptoms are stronger in cancer prevention.Surgery can prolong survival time and improve the survival rate for cancer patients, so people should consider have a surgery as soon as possible.In addition, radiotherapy and chemotherapy also may work in the therapy, which is consistent with previous results (DeAngelis et al, 2002).
In conclusion, the living conditions of patients with advanced tumors are generally poor.In order to strengthen prevention, prolong their survival time and even improve life quality, following aspects are needed to be done.First of all, early detection, early diagnosis, surgical treatment, radiotherapy and chemotherapy are important.Recent studies show that low-dose computer tomography scan can be used to screen lung cancer effectively and reduce its mortality (Aberle and Brown, 2008;Coche, 2008).Secondly, comprehensive interventions including psychological intervention, dietary guidance and exercise intervention are required (Peters et al, 1995;Cunningham et al, 1998;Glare et al, 2008).Thirdly, self-management educations should be promoted for patients to improve compliance and effectiveness of the treatment, to develop good habits and to alleviate the pressure.Lastly, palliative treatments are necessary for advanced cancer patients to prolong survival and improve life quality.For example, zoledronic acid in combination with chemotherapy can reduce skeleton related events in non-small cell lung cancer patients (Coleman et al., 2010).Percutaneous placement of metal stents to patients with malignant biliary obstruction were beneficial with regard to survival time (O'Brien et al., 1995).Analgesic can substantially reduce patient's suffering.  .
development research programs of Liaoning Province