Background: The relationship between low socioeconomic status (SES) and aggressiveness of end-of-life (EOL) care in cancer patients of working age (older than 18 years and younger than 65 years) is not clear. We assessed the association between aggressiveness of EOL care and differences in SES among working-age terminal cancer patients from Taiwan between 2009 and 2011.
Methods: A total of 32,800 cancer deaths were identified from the Taiwan National Health Insurance Research Database. The indicators of aggressive EOL care (chemotherapy, more than one emergency room [ER] visit or hospital admission, more than 14 days of hospitalization, intensive care unit [ICU] admission, and death in an acute care hospital) in the last month of life were examined. The associations between SES and the indicators were explored.
Results: Up to 81% of the cancer deaths presented at least one indicator of aggressive EOL care. Those who were aged 35-44 years and male, had low SES, had metastatic malignant disease, lived in urban areas, or were in hospitals with more abundant health care resources were more likely to receive aggressive EOL care. In multilevel logistic regression analyses, high-SES cancer deaths had less chemotherapy (p < .001), fewer ER visits (p < .001), fewer ICU admissions (p < .001), and lower rates of dying in acute hospitals (p < .001) compared with low-SES cancer deaths.
Conclusion: Working-age terminal cancer patients in Taiwan received aggressive EOL care. EOL cancer care was even more aggressive in those with low SES. Public health strategies should continue to focus on low-SES patients to provide them with better EOL cancer care.
摘要
背景. 低社会经济地位（SES）与工作年龄（18 ∼ 65 岁）癌症患者积极的临终（EOL）治疗之间的关系尚未明确。本研究在 2009 ∼ 2011 年间评估了台湾地区工作年龄罹患终末期癌症患者积极的 EOL 治疗与 SES 差异之间的相关性。
方法. 从台湾地区全民健康保险研究数据库共鉴别出 32 800 例癌症死亡患者。研究调查了患者死亡前一个月内积极 EOL 治疗的指标[化疗、急诊（ER）就诊或入院≥1 次、住院≥14 天、重症监护室（ICU）住院、在综合医院死亡]，并探索了 SES 与这些指标之间的相关性。
结果. 81%的癌症死亡者至少有一项积极 EOL 治疗指标。年龄在 35 ∼ 44 岁之间、男性、低 SES、转移性恶性肿瘤、生活在城市地区或在有较多卫生健康资源的医院就诊的癌症患者接受积极 EOL 治疗的可能性更高。多层次 logistic 回归分析中，与低 SES 癌症死亡者相比，高 SES 癌症死亡者化疗（P < 0.001）、ER 就诊次数（P < 0.001）、ICU 住院次数均较少（P < 0.001），在综合医院死亡的比例也较低（P < 0.001）。
结论. 台湾地区工作年龄的终末期癌症患者接受了积极的EOL治疗。而低SES人群接受了更为积极的EOL癌症治疗。公共卫生策略应该继续关注低SES患者，为他们提供更好的EOL癌症治疗。The Oncologist 2014;19:1241–1248
Keywords: Cancer; End-of-life care; Socioeconomic status; Working age; Young adults.
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