title: Invasive procedures in the elderly after stage IV cancer diagnosis.
abstract: BACKGROUND
  Invasive procedures are resource intense and may be associated with substantial morbidity. These harms must be carefully balanced with the benefits gained in life expectancy and quality of life. Prior research has demonstrated an increasing aggressiveness of care in cancer patients at the end-of-life. To better characterize surgical care in this setting, we sought to examine trends in the use of invasive procedures in patients diagnosed with metastatic cancer on presentation.
  
  
  METHODS
  Using Surveillance Epidemiology and End Results -Medicare data, we identified invasive procedure claims from 1994-2009 for patients diagnosed with incident stage IV breast, colorectal, lung, and prostate cancer patients in 1995-2006. We grouped procedures into surgically relevant categories, using an adaptation of the Clinical Classifications Software, and measured utilization and relative changes over time.
  
  
  RESULTS
  Of stage IV patients diagnosed in 2002-2006, 96% underwent a procedure during the course of their cancer care including 63% after the diagnostic period, and 25% in the last month of life. Between 1996 and 2006, minimal change was observed in utilization during the diagnostic period (+1.5%). However, there were significant increases during continuing care (+20.7%) and the last month of life (+21.5%). Procedures consistent with primary tumor resection decreased, whereas those with probable palliative intent and those unrelated to cancer increased.
  
  
  CONCLUSIONS
  Nearly all patients who present with metastatic cancer undergo invasive procedures. Although overall utilization is increasing, the specific procedure types indicate that it may be appropriate, enhancing the quality of life in this vulnerable population.
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; Department of Plastic & Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
authors.forename: Alvin C
authors.initials: AC
authors.lastname: Kwok
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Electronic address: yhu@bidmc.harvard.edu.
authors.forename: Yue-Yung
authors.initials: YY
authors.lastname: Hu
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Dodgion
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Wei
authors.initials: W
authors.lastname: Jiang
authors.affiliation: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Gladys V
authors.initials: GV
authors.lastname: Ting
authors.affiliation: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Nathan
authors.initials: N
authors.lastname: Taback
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.affiliation: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin; Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Caprice C
authors.initials: CC
authors.lastname: Greenberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008297:Male; D009369:Neoplasms / Q000175:diagnosis / Q000601:surgery*; D018426:SEER Program; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000706:statistics & numerical data*
keywords: End-of-life; Procedure utilization; Stage IV cancer