Supportive Care in Cancer

, Volume 26, Issue 10, pp 3619–3625 | Cite as

Advanced imaging and hospice use in end-of-life cancer care

  • Michaela A. Dinan
  • Lesley H. Curtis
  • Soko Setoguchi
  • Winson Y. Cheung
Original Article



Advanced imaging can inform prognosis and may be a mechanism to de-escalate unnecessary end-of-life care in patients with cancer. Associations between greater use of advanced imaging and less-aggressive end-of-life care in real-world practice has not been examined.


We conducted a retrospective analysis of SEER-Medicare data on patients who died from breast, lung, colorectal, or prostate cancer between 2002 and 2007. Hospital referral region (HRR)-level use of computerized tomography (CT), magnetic resonance imaging, and positron emission tomography was categorized by tertile of imaging use and correlated with hospice enrollment overall and late hospice enrollment using multivariable logistic regression.


A total of 55,058 patients met study criteria. Hospice use ranged from 50.8% (colorectal cancer) to 62.1% (prostate cancer). In multivariable analyses, hospital referral regions (HRRs) with high rates of CT imaging were associated with lower odds of hospice enrollment (odds ratio, 0.80; 95% CI, 0.70–0.90) and late enrollment among those who did enroll (odds ratio, 1.49; 95% CI, 1.26–1.76). HRRs with the highest rates of CT use were predominantly located in the Midwest and Northeast and associated with higher percentage population of black patients (14.5 vs 5.6%), greater comorbidity (28.4 vs 23.7%), metropolitan residence (93.9 vs 78.5%), and less than high school education (26.4 vs 19.3%).


In this population-based retrospective study, we did not observe evidence that overall and timely hospice are associated with higher rates of imaging near the end of life. An observed association between higher rates of imaging, particularly CT, may be explained in part by HRR-level differences in practice patterns and patient demographic characteristics. Further research is warranted to explore the ability of oncologic imaging to appropriately de-escalate care.


Breast neoplasms Colorectal neoplasms Diagnostic imaging Hospice care Lung neoplasms Outcome assessment (health care) Prostatic neoplasms 


Additional contributions

Damon M. Seils, MA, Duke University, assisted with manuscript preparation. Mr. Seils did not receive compensation for his assistance apart from his employment at the institution where the work was conducted.


Dr. Dinan was supported by grant KM1CA156687 from the National Cancer Institute.

Compliance with ethical standards

Ethical approval

The institutional review board of the Duke University Health System approved the study. For this type of study, formal consent is not required. This article does not contain any studies with animals performed by any of the authors.

Financial disclosures

None reported.


The content of the manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Supplementary material

520_2018_4223_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 19 kb)
520_2018_4223_MOESM2_ESM.docx (22 kb)
ESM 2 (DOCX 22 kb)
520_2018_4223_MOESM3_ESM.docx (23 kb)
ESM 3 (DOCX 23 kb)


  1. 1.
    Riley GF, Lubitz JD (2010) Long-term trends in Medicare payments in the last year of life. Health Serv Res 45:565–576CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bergman J, Saigal CS, Lorenz KA, Hanley J, Miller DC, Gore JL, Litwin MS, Urologic Diseases in America Project (2011) Hospice use and high-intensity care in men dying of prostate cancer. Arch Intern Med 171:204–210Google Scholar
  3. 3.
    Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC (2011) Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29:1587–1591CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Keating NL, Landrum MB, Lamont EB, Earle CC, Bozeman SR, McNeil BJ (2010) End-of-life care for older cancer patients in the veterans health administration versus the private sector. Cancer 116:3732–3739CrossRefPubMedGoogle Scholar
  5. 5.
    Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK (2004) Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ 328:607CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Foley KM (2005) Improving palliative care for cancer: a national and international perspective. Gynecol Oncol 99:S213–SS214CrossRefPubMedGoogle Scholar
  7. 7.
    Yasaitis L, Fisher ES, Skinner JS, Chandra A (2009) Hospital quality and intensity of spending: is there an association? Health Aff (Millwood) 28:w566–w572CrossRefGoogle Scholar
  8. 8.
    Barnato AE, McClellan MB, Kagay CR, Garber AM (2004) Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res 39:363–375CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW (2009) Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood) 28:1475–1484CrossRefGoogle Scholar
  10. 10.
    Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315–321CrossRefPubMedGoogle Scholar
  11. 11.
    Warren JL, Barbera L, Bremner KE, Yabroff KR, Hoch JS, Barrett MJ, Luo J, Krahn MD (2011) End-of-life care for lung cancer patients in the United States and Ontario. J Natl Cancer Inst 103:853–862CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Yabroff KR, Lamont EB, Mariotto A, Warren JL, Topor M, Meekins A, Brown ML (2008) Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 100:630–641CrossRefPubMedGoogle Scholar
  13. 13.
    Krahn MD, Zagorski B, Laporte A, Alibhai SM, Bremner KE, Tomlinson G, Warde P, Naglie G (2010) Healthcare costs associated with prostate cancer: estimates from a population-based study. BJU Int 105:338–346CrossRefPubMedGoogle Scholar
  14. 14.
    Miller SC, Gozalo P, Mor V (2001) Hospice enrollment and hospitalization of dying nursing home patients. Am J Med 111:38–44CrossRefPubMedGoogle Scholar
  15. 15.
    Guadagnolo BA, Huo J, Liao KP, Buchholz TA, Das P (2013) Changing trends in radiation therapy technologies in the last year of life for patients diagnosed with metastatic cancer in the United States. Cancer 119:1089–1097CrossRefPubMedGoogle Scholar
  16. 16.
    McCarthy EP, Burns RB, Ngo-Metzger Q, Davis RB, Phillips RS (2003) Hospice use among Medicare managed care and fee-for-service patients dying with cancer. JAMA 289:2238–2245CrossRefPubMedGoogle Scholar
  17. 17.
    Ngo-Metzger Q, McCarthy EP, Burns RB, Davis RB, Li FP, Phillips RS (2003) Older Asian Americans and Pacific islanders dying of cancer use hospice less frequently than older white patients. Am J Med 115:47–53CrossRefPubMedGoogle Scholar
  18. 18.
    Saito AM, Landrum MB, Neville BA, Ayanian JZ, Weeks JC, Earle CC (2011) Hospice care and survival among elderly patients with lung cancer. J Palliat Med 14:929–939CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Teno JM, Gozalo PL, Bynum JP, George EK, Groeneweg M, Norbruis OF, Tjon A Ten W, van Wering HM, Dijkgraaf MGW, Merkus MP, Benninga MA (2013) Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 309:470–477CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Dinan MA, Curtis LH, Hammill BG, Patz EF Jr, Abernethy AP, Shea AM, Schulman KA (2010) Changes in the use and costs of diagnostic imaging among Medicare beneficiaries with cancer, 1999-2006. JAMA 303:1625–1631Google Scholar
  21. 21.
    Hu YY, Kwok AC, Jiang W, Taback N, Loggers ET, Ting GV, Lipsitz SR, Weeks JC, Greenberg CC (2012) High-cost imaging in elderly patients with stage IV cancer. J Natl Cancer Inst 104:1164–1172CrossRefPubMedGoogle Scholar
  22. 22.
    Shintani SA, Foote RL, Lowe VJ, Brown PD, Garces YI, Kasperbauer JL (2008) Utility of PET/CT imaging performed early after surgical resection in the adjuvant treatment planning for head and neck cancer. Int J Radiat Oncol Biol Phys 70:322–329CrossRefPubMedGoogle Scholar
  23. 23.
    Maziak DE, Darling GE, Inculet RI, Gulenchyn KY, Driedger AA, Ung YC, Miller JD, Gu CS, Cline KJ, Evans WK, Levine MN (2009) Positron emission tomography in staging early lung cancer: a randomized trial. Ann Intern Med 151:221–218, W-48Google Scholar
  24. 24.
    van Tinteren H, Hoekstra OS, Smit EF, van den Bergh JH, Schreurs AJ, Stallaert RA, van Velthoven PC, Comans EF, Diepenhorst FW, Verboom P, van Mourik JC, Postmus PE, Boers M, Teule GJ (2002) Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet 359:1388–1393CrossRefPubMedGoogle Scholar
  25. 25.
    Fischer B, Lassen U, Mortensen J, Larsen S, Loft A, Bertelsen A, Ravn J, Clementsen P, Høgholm A, Larsen K, Rasmussen T, Keiding S, Dirksen A, Gerke O, Skov B, Steffensen I, Hansen H, Vilmann P, Jacobsen G, Backer V, Maltbaek N, Pedersen J, Madsen H, Nielsen H, Højgaard L (2009) Preoperative staging of lung cancer with combined PET-CT. N Engl J Med 361:32–39CrossRefPubMedGoogle Scholar
  26. 26.
    Brown ML, Riley GF, Schussler N, Etzioni R (2002) Estimating health care costs related to cancer treatment from SEER-Medicare data. Med Care 40:IV-104-17Google Scholar
  27. 27.
    Warren JL, Harlan LC, Fahey A, Virnig BA, Freeman JL, Klabunde CN, Cooper GS, Knopf KB (2002) Utility of the SEER-Medicare data to identify chemotherapy use. Med Care 40:IV-55-61Google Scholar
  28. 28.
    Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF (2002) Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 40:IV–3-18PubMedGoogle Scholar
  29. 29.
    Wennberg JE, Fisher ES, Goodman DC, Skinner JS (2008) Tracking the Care of Patients with severe chronic illness: the Dartmouth atlas of health care 2008. The Dartmouth Institute for Health Policy and Clinical Practice. Lebanon, New HampshireGoogle Scholar
  30. 30.
    Fairfield KM, Lucas FL, Earle CC, Small L, Trimble EL, Warren JL (2010) Regional variation in cancer-directed surgery and mortality among women with epithelial ovarian cancer in the Medicare population. Cancer 116:4840–4848CrossRefPubMedGoogle Scholar
  31. 31.
    Polsky D, Armstrong KA, Randall TC, Ross RN, Even-Shoshan O, Rosenbaum PR, Silber JH (2006) Variation in chemotherapy utilization in ovarian cancer: the relative contribution of geography. Health Serv Res 41:2201–2218CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Brooks GA, Li L, Sharma DB, Weeks JC, Hassett MJ, Yabroff KR, Schrag D (2013) Regional variation in spending and survival for older adults with advanced cancer. J Natl Cancer Inst 105:634–642CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    US Bureau of Labor Statistics (2012) Consumer Price Index. Accessed 6 February 2012
  34. 34.
    Cintron A, Hamel MB, Davis RB, Burns RB, Phillips RS, McCarthy EP (2003) Hospitalization of hospice patients with cancer. J Palliat Med 6(5):757–768CrossRefPubMedGoogle Scholar
  35. 35.
    Hu YY, Kwok AC, Jiang W, Burns RB, Phillips RS, McCarthy EP (2012) High-cost imaging in elderly patients with stage IV cancer. J Natl Cancer Inst 104:1164–1172CrossRefPubMedGoogle Scholar
  36. 36.
    Primo DM, Jacobsmeier ML, Milyo J (2007) Estimating the impact of state policies and institutions with mixed-level data. State Politics and Policy Quarterly 7:446–459CrossRefGoogle Scholar
  37. 37.
    Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz TA, Shih YC (2013) Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States. J Clin Oncol 31:80–87CrossRefPubMedGoogle Scholar
  38. 38.
    Hamel MB, Lynn J, Teno JM, Covinsky KE, Wu AW, Galanos A, Desbiens NA, Phillips RS (2000) Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT. J Am Geriatr Soc 48:S176–S182CrossRefPubMedGoogle Scholar
  39. 39.
    Hinton J (1994) Which patients with terminal cancer are admitted from home care? Palliat Med 8:197–210CrossRefPubMedGoogle Scholar
  40. 40.
    Fairfield KM, Murray KM, Wierman HR, Han PK, Hallen S, Miesfeldt S, Trimble EL, Warren JL, Earle CC (2012) Disparities in hospice care among older women dying with ovarian cancer. Gynecol Oncol 125:14–18CrossRefPubMedGoogle Scholar
  41. 41.
    MedPAC (2010) Report to congress: aligning incentives in Medicare. Medicare Payment Advisory Commission, WashingtonGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Michaela A. Dinan
    • 1
    • 2
  • Lesley H. Curtis
    • 1
    • 2
  • Soko Setoguchi
    • 3
  • Winson Y. Cheung
    • 4
  1. 1.Duke Clinical Research InstituteDuke University School of MedicineDurhamUSA
  2. 2.Department of Population Health SciencesDuke University School of MedicineDurhamUSA
  3. 3.Department of EpidemiologyRutgers School of Public HealthPiscatawayUSA
  4. 4.Department of OncologyUniversity of CalgaryCalgaryCanada

Personalised recommendations