Barriers to palliative care access in patients with brain metastases: A comprehensive national study.

Abstract

12095 Background: Palliative care (PC) improves the quality of life for patients with advanced cancer, including those with brain metastases (BM). Despite nearly 170,000–200,000 cases of BM annually in the United States, evidence supporting utilization of early PC in malignant brain tumors remains limited. This study aimed to identify factors influencing access to PC for patients with BM from lung, breast, and colorectal cancer to delineate patient uptake of PC. Methods: This retrospective cohort study analyzed the National Cancer Database (NCDB) data (2010-2021) for patients with BM from lung, breast, and colorectal cancer. Variables analyzed included age, sex, race, ethnicity, facility type, insurance status, socioeconomic factors, and primary cancer site. The primary outcome was receipt of PC. Descriptive statistics summarized patient characteristics, and logistic regression identified predictors of access to PC, reporting odds ratios (OR) with 95% confidence intervals (CIs). Results: Of 214,940 patients with BM, 94% had lung cancer, 4.2% had breast cancer, and 1.7% had colorectal cancer. The cohort was 50.9% female, 82.6% White, 12.2% Black, 3.8% Asian, 96.4% non-Hispanic, and 3.6% Hispanic. In the multivariate analysis, older patients had lower odds of receiving PC compared to patients aged 18-59 (60-69: OR 0.95, 95% CI 0.93-0.98; 70+: OR 0.88, 95% CI 0.86-0.91; P < 0.001), while sex was not associated with PC (OR 0.99, 95% CI 0.97-1.01; P = 0.333). Compared to White patients, Black (OR 0.96, 95% CI 0.93-0.99; P = 0.014), and Asian (OR 0.95, 95% CI 0.91-1.00; P = 0.066) patients had lower likelihood of PC. Hispanics were also less likely to receive PC (OR 0.85, 95% CI 0.80-0.90; P < 0.001). Integrated facilities (i.e., part of a larger network with centralized cancer care) had a lower probability of providing PC than community hospitals (OR 0.97, 95% CI 0.95-0.99; P = 0.002), whereas academic facilities showed no differences (P = 0.105). Medicaid patients had slightly higher odds of receiving PC than those with private insurance (OR 1.04, 95% CI 1.00-1.07; P = 0.026), while Medicare and other government insurance showed no significant differences. Medicaid expansion improved access (January 2014: OR 1.55, 95% CI 1.50-1.60; late expansion: OR 1.55, 95% CI 1.50-1.61; P < 0.001). Patients living > 10 miles from a facility had lower odds of access (OR 0.97, 95% CI 0.94-0.99; P = 0.002). Compared to patients with breast cancer, those with lung cancer had lower odds (OR 0.92, 95% CI 0.87-0.96; P < 0.001), and colorectal cancer patients had the lowest odds (OR 0.73, 95% CI 0.67-0.80; P < 0.001) of accessing PC. Conclusions: Significant disparities in PC access among patients with BM exists. Age, racial and ethnic subgroups, geographic barriers, and primary cancer type impact uptake of PC. Targeted interventions, including strategies to improve access for underserved populations, are needed to increase health equity among BM patients.