Black patients with advanced cancer were more likely than whites to
die in a hospital intensive care unit, reflecting a greater preference
among blacks for life-extending treatment even in the face of a terminal
prognosis, according to a study led by researchers at Dana-Farber
Cancer Institute in Boston.
The findings (abstract 6506) will be presented at the annual meeting
of the American Society of Clinical Oncology in Chicago on Monday, June
2, 3 – 6 p.m. CT, South Building, Hall100B.
The report included interview data showing that blacks more often
answered yes to questions such as, "Would you want the doctors here to
do everything they can to keep you alive, even if you were going to die
in a day or two?"
"This is the first study focused on black/white differences that
prospectively asked [terminal cancer patients] what kind of care they
wanted at the end of life, and then documented the kind of care they
actually received and the place of their death," said Elizabeth Trice,
MD, PhD, of Dana-Farber, lead author.
Although they ruled out a number of possible explanations for the
black/white differences, the investigators weren't able to identify
precisely why blacks tended to prefer more-aggressive care.
"There is something different about the way black patients and white
patients approach the end of life," Trice said, which may be based in
cultural attitudes, religious beliefs, and how thoroughly they have been
informed about and comprehend their prognosis, among other things.
Data on the preferences was obtained from the Coping with Cancer study
led by Holly Prigerson, PhD, director of the Center for Psycho-social
Oncology and Palliative Care Research at Dana-Farber and an associate
professor of psychiatry at Harvard Medical School. That study is
recruiting 800 cancer patients and their informal caregivers, such as
The researchers recorded the location of death for 231 white and 61
black patients who had stage IV metastatic cancer, and who had been
interviewed when they entered the study. Black patients were over four
times more likely to die in a hospital ICU than white patients, they
The researchers, using multivariable models, found that the increased
likelihood of dying in the ICU for black compared to white patients was
not explained by differences in education, physical or mental health,
insurance, social support, doctor-patient communication, or advance care
planning, when taking into account the patient's own preference for
more-aggressive care. It was clear that a patient's preference for
aggressive care was the strongest factor in predicting death in an ICU.
In their initial interviews, black patients reported having a higher
quality of life than their white counterparts and appeared more at
peace, Trice said, which could be a factor in opting for a treatment
plan aimed at extending life.
Prigerson, the senior author of the study, said the crucial question
to be explored is whether the treatment preferences that explain the
black/white disparities in ICU death are informed preferences or not.
Toward that end, Trice has developed a research tool for assessing
patients' knowledge of risks and benefits of life-extending therapies.
If further research determines that blacks and whites are not equally
well-informed about these risks and benefits, interventions aimed at
eliminating this disparity should be considered, said the scientists.
The study's co-authors are Matthew Nilsson, Alexi Wright, MD, Tracy
Balboni, MD, K. "Vish" Viswanath, PhD, and Karen Emmons, PhD, of
Dana-Farber; Susan DeSanto-Madeya, RN, DNS, of the University of
Massachusetts, Boston; and M. Elizabeth Paulk, MD, and Heather
Stieglitz, PhD, of the University of Texas Southwestern Medical Center,
Prigerson is supported by NIH grants ca106370 and mh63892.
Dana-Farber Cancer Institute (www.dana-farber.org)
is a principal teaching affiliate of the Harvard Medical School and is
among the leading cancer research and care centers in the United States.
It is a founding member of the Dana-Farber/Harvard Cancer Center
(DF/HCC), designated a comprehensive cancer center by the National