Referral patterns among patients with metastatic breast cancer in an integrated palliative care program.

163 Background: ASCO recommends palliative care (PC) concurrently with oncologic treatment for patients with metastatic disease and there is emerging data about the benefits of early PC. However, little is known about referral patterns to specialty PC among patients who die of metastatic breast cancer.

METHODS: After years of offering a stand-alone outpatient PC consult service in our comprehensive cancer center, we established an integrated PC program in breast oncology (the "Advanced Breast Cancer (ABC) Program") with a care coordinator, PC physician, and co-location with oncology. Among patients who died, we analyzed referral patterns, program participation, and end-of-life quality outcomes from October 2014 through May 2015.

RESULTS: 38 of 108 patients (35.2%) referred to and seen in ABC died, with an average of 2.9 PC visits (range 1-17) and 7 months (range 0-20) between referral and death. Reasons for referral among ABC patients who died included: symptom management (15 patients, 39.5%); goals of care discussions (12, 31.6%); psychosocial support (5, 13.2%); discharge referral from the inpatient PC team (4, 10.5%); and new diagnosis of metastatic disease (3, 7.9%). At the time of referral, average time since metastatic diagnosis was 23.6 months (range: 0-106); 10 patients (26.3%) had received > 3 lines of treatment. 15 referred patients (13.9%) died but were not seen by ABC: of those, 6 initiated hospice before they could be seen; 5 initially declined or deferred the referral but then were too sick to be seen in clinic by the time they agreed; and 4 were unwilling to accept extra appointments or did not follow-up to repeated outreach. 24 ABC patients who died (63.2%) were seen early (> 90 days before death), whereas in the year prior to the ABC clinic, among patients who died, only 11 of 44 (25%) who had received PC consultation received it early. 19 of 33 (57.6%) ABC patients for whom data was available utilized hospice, with only 2 (5.3%) using hospice < 3 days.

CONCLUSIONS: Embedding and integrating a PC practice in breast oncology resulted in patients being seen earlier. Future efforts should be directed at further increases in earlier referrals by oncologists and in facilitating patient acceptance of early referrals.