women from more extensive debilitating treat-ments, and it could save her life.”
“I want women to continue with currentscreening as recommended,” said Elmore. “Ithink they also need to realize that screening isnot perfect or foolproof. Women need to payattention to their bodies and seek medical at-tention if they notice an abnormality that wor-ries them.”
Smith and Elmore also agree that it is im-portant to find ways to improve the quality ofmammography and breast cancer screening inthe United States.
“I hope the results of our study will serve asan impetus to investigators and funding agen-cies,” Elmore said. “We can’t become compla-cent about screening.”
PHYSICIAN INVOLVEMENT BOOSTS HOSPICEREFERRAL
Nursing home patients are more likely toenroll in hospice care at the end of life if theirhealth care team is involved in the decision torefer them to a program. That was the conclu-sion of a study published recently in JAMA(2005;294:211–217) that examined an inter-vention designed to pull physicians into theprocess sooner.
“Hospice is the gold standard for end of lifecare,” said David Casarett, MD, MA, lead au-thor of the new study. “For most patients andfamilies in most settings, the single best way toget access to a highly-trained interdisciplinaryteam is through hospice.”
Hospice services are covered by Medicarefor people 65 and older. Yet many patientswho could benefit from hospice services neverenroll, or only do so within a few weeks—oreven a few days—of their death.
“If we could take care of people for longer,we could do more good,” said Casarett, who isdirector of the Palliative Care Consult Serviceat the Philadelphia Veterans Affairs (VA) Med-ical Center.
Casarett has done previous studies of hospice,looking at factors that lead people to enroll. A
common theme emerging in the earlier work, hesaid, is that “patients and families often wait forphysicians to begin the hospice discussion—andthey wait and they wait and they wait.”
Doctors may be reluctant to bring up the topicof hospice because they are not certain how thepatient or family might respond, Casarett said.
“Enough of us as physicians have had thatexperience where you come into a room andsay, ‘Things are looking bad, maybe it’s time tothink about hospice,’ and you’re met with adistraught patient or family member whothinks you’re abandoning them,” he said. “Allit takes is one bad conversation like that tomake a physician gun shy.”
With this latest work, he and his colleagueshoped to find a way to “jumpstart” this poten-tially difficult conversation.
The study included residents of three nurs-ing homes, including the VA facility whereCasarett works, who were randomized intotwo groups. Trained interviewers spoke withthe residents (or the person responsible formaking decisions about their care) to iden-tify hospice-appropriate patients. The controlgroup received usual care. Hospice-appropriatepatients were given a brief description of hos-pice services and told they could learn more byspeaking with their physician.
But the researchers asked members of theintervention group for permission to contacttheir doctor directly about enrolling in hospice.Those doctors then got a fax from the research-ers letting them know they had a patient whowas a good candidate for hospice care andasking them to authorize a consultation.
Of 35 patients in the intervention groupwho were candidates for hospice, 21 enrolledin a program within 30 days, and six additionalpatients had enrolled by the 6-month mark. Of49 hospice-eligible patients in the controlgroup, just one enrolled in a program in thefirst 30 days, and five additional patients hadenrolled by the 6-month mark.
People in the intervention group also spentmuch more time in hospice (mean 64 days)than people in the control group (mean 14
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days). Also, people in the intervention groupwere much less likely to be hospitalized thanpeople in the control group.
In general, Casarett said, people who are inhospice care have decided they do not want tobe in a hospital setting—although, of course,they are free to change their minds and gethospital care if it is needed.
Another important finding from the study isthat families of people in the interventiongroup were more satisfied with the end-of-lifecare their loved one received than families ofpeople in the control group. That was trueeven though people in the intervention groupwere no more likely to be enrolled in hospiceat the time of their death, nor to die in thenursing home rather than an acute care setting.
“But the main difference is that they spentmore time in hospice. So even if this interven-tion doesn’t result in more people dying inhospice, they spend more time in hospice.Who’s enrolled at the time they die may notmean as much as the care they got the previousweek or previous month,” explained Casarett.
“Hospice does a lot to prepare patients andalso families for death, both in terms of focus-ing on pain and symptom management, andemotional and spiritual support,” said Casarett.“But we don’t know what hospice did to makepeople more satisfied. Was it better pain man-agement? Was it better emotional support? Wejust know hospice is very important in improv-ing satisfaction with care.”
Casarett said his group is doing other studiesto determine exactly what it is about hospicethat helps families feel better about the caretheir loved ones get.
SWITCH TO AROMATASE INHIBITOR BETTER THANCONTINUING TAMOXIFEN
Breast cancer patients who switch to thearomatase inhibitor, anastrozole, after 2 yearson tamoxifen do better than women who con-tinue taking the full 5-year course of the olderdrug, results of a new analysis indicate. Writingin The Lancet (2005;366:455–462), researchers
from Austria and Germany report the com-bined findings of the Austrian Breast and Colo-rectal Cancer Study Group trial 8 (ABCSG trial8) and the Arimidex/Nolvadex 95 trial(ARNO 95).
The trials involved more than 3,000 womenwho received standard treatment for early-stagebreast cancer (lumpectomy plus radiation ormastectomy) followed by tamoxifen. After 2years on the drug, 1,608 women were random-ized to continue tamoxifen, and 1,618 wereassigned to switch to anastrozole.
After median follow up of 28 months, theresearchers reported a 40% decrease in risk oflocal or distant metastasis or contralateral breastcancer in the women who took anastrozolecompared with the tamoxifen group. In abso-lute terms, anastrozole conferred a 3.1% event-free survival benefit over tamoxifen (95.8%versus 92.7%).
There was no significant difference in over-all survival between the groups after 3 years. Asexpected, however, the drugs did have differ-ent side effects. Women on anastrozole expe-rienced significantly more bone fractures (oddsratio [OR] 2.14) and significantly fewerthromboses (OR 0.25) than women on tamox-ifen. Women on anastrozole also reportedmore bone pain and nausea.
Lead author Raimund Jakesz, MD, of theVienna Medical University, says the findingssupport those of earlier trials—in particular theArimidex, Tamoxifen, Alone or in Combina-tion (ATAC) trial—that found aromatase in-hibitors superior to tamoxifen for preventingrecurrences, particularly in the first 2 years oftherapy. They also suggest that women whohave taken 2 to 3 years of tamoxifen therapyshould be switched to an aromatase inhibitorfor their remaining years of hormonal treat-ment.
That group of patients is likely gettingsmaller, said Christy Russell, MD, of the Uni-versity of Southern California’s Norris Com-prehensive Cancer Center. Russell was notinvolved in the new research. She serves as
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