Original Article

Multicenter Cohort Study on the Survival Time

of Cancer Patients Dying at Home or in a Hospital:
Does Place Matter?
Jun Hamano, MD1; Takashi Yamaguchi, MD, PhD 2; Isseki Maeda, MD, PhD3 ; Akihiko Suga, MD4 ; Takayuki Hisanaga, MD5 ;
Tatsuhiko Ishihara, MD 6; Tomoyuki Iwashita, MD 7; Keisuke Kaneishi, MD, PhD8; Shohei Kawagoe, MD9;

Printed by [American Cancer Society Journals - 187.086.077.247 - /doi/epdf/10.1002/cncr.29844] at [28/04/2021].

Toshiyuki Kuriyama, MD, PhD10 ; Takashi Maeda, MD11 ; Ichiro Mori, MD12 ; Nobuhisa Nakajima, MD, PhD13 ;
Tomohiro Nishi, MD 14; Hiroki Sakurai, MD 15 ; Satofumi Shimoyama, MD, PhD16; Takuya Shinjo, MD 17; Hiroto Shirayama, MD 18;
Takeshi Yamada, MD, PhD19; and Tatsuya Morita, MD 20

BACKGROUND: Although the place of death has a great influence on the quality of death and dying for cancer patients, whether the
survival time differs according to the place of death is unclear. The primary aim of this study was to explore potential differences in
the survival time of cancer patients dying at home or in a hospital. METHODS: This multicenter, prospective cohort study was con-
ducted in Japan from September 2012 through April 2014 and involved 58 specialist palliative care services. RESULTS: Among the
2426 patients recruited, 2069 patients were analyzed for this study: 1582 receiving hospital-based palliative care and 487 receiving
home-based palliative care. A total of 1607 patients actually died in a hospital, and 462 patients died at home. The survival of patients
who died at home was significantly longer than the survival of patients who died in a hospital in the days’ prognosis group (estimated
median survival time, 13 days [95% confidence interval (CI), 10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days]; P 5 .006) and in the
weeks’ prognosis group (36 days [95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5 days]; P 5 .007) as defined by Prognosis in
Palliative Care Study predictor model A. No significant difference was identified in the months’ prognosis group. Cox proportional

Corresponding author: Jun Hamano, MD, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575,
Japan; Fax: (011) 81-298-53-3189; junhamano@md.tsukuba.ac.jp
1
Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan; 2Department of Palliative Medicine, Kobe University Graduate School of
Medicine, Kobe, Japan; 3 Department of Palliative Medicine, Graduate School of Medicine, Osaka University, Suita, Japan; 4Department of Palliative Medicine, Shi-
zuoka Saiseikai General Hospital, Suruga, Japan; 5Tsukuba Medical Center Foundation, Tsukuba, Japan; 6Palliative Care Department, Okayama Saiseikai General
Hospital, Okayama City, Japan; 7Matsue City Hospital, Matsue City, Japan; 8Department of Palliative Care Unit, Japan Community Health Care Organization (JCHO)
Tokyo Shinjuku Medical Center, Tokyo, Japan; 9Aozora Clinic, Matsudo City, Japan; 10Department of Palliative Medicine, Wakayama Medical University Hospital
Oncology Center, Wakayama, Japan; 11 Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Ja-
pan; 12 Gratia Hospital Hospice, Mino, Japan; 13 Department of Palliative Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan; 14Kawasaki
Comprehensive Care Center, Kawasaki Municipal Ida Hospital, Kawasaki, Japan; 15Palliative Care Team, Cancer Institute Hospital, Tokyo, Japan; 16 Department of
Palliative Care, Aichi Cancer Center Hospital, Nagoya, Japan; 17 Shinjo Clinic, Kobe Shinjo Clinic, Kobe, Japan; 18Iryouhoujinn Takumikai Osaka Kita Homecare Clinic,
Osaka City, Japan; 19 Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan; 20Palliative and Supportive Care
Division, Seirei Mikatahara General Hospital, Hamamatsu-Shi, Japan

This study was performed by the Japan Prognostic Assessment Tools Validation study group. The participating investigators (and study sites) were as follows:
Satoshi Inoue, MD (Seirei Hospice, Seirei Mikatahara General Hospital); Masayuki Ikenaga, MD (Hospice Children’s Hospice Hospital, Yodogawa Christian Hospital);
Yoshihisa Matsumoto, MD, PhD (Department of Palliative Medicine, National Cancer Center Hospital East); Mika Baba, MD (Department of Palliative Care, Saito
Yukoukai Hospital); Ryuichi Sekine, MD (Department of Pain and Palliative Care, Kameda Medical Center); Takashi Yamaguchi, MD, PhD (Department of Palliative
Medicine, Kobe University Graduate School of Medicine); Takeshi Hirohashi, MD (Department of Palliative Care, Mitui Memorial Hospital); Tsukasa Tajima, MD (Depart-
ment of Palliative Medicine, Tohoku University Hospital); Ryohei Tatara, MD (Osaka City General Hospital, Department of Palliative Medicine); Hiroaki Watanabe, MD
(Komaki City Hospital); Hiroyuki Otani, MD (Department of Palliative Care Team and Palliative and Supportive Care, National Kyushu Cancer Center); Chizuko Taki-
gawa, MD (Department of Palliative Care, KKR Sapporo Medical Center); Yoshinobu Matsuda, MD (Department of Psychosomatic Medicine, National Hospital); Hiroka
Nagaoka, MD (Department of Medical Social Service Center for Palliative, University of Tsukuba); Masanori Mori, MD (Seirei Hamamatsu General Hospital); Yo Tei, MD
(Seirei Hospice, Seirei Mikatahara General Hospital); Shuji Hiramoto, MD (Department of Oncology, Mitsubishi Kyoto Hospital); Akihiko Suga, MD (Department of Palli-
ative Medicine, Shizuoka Saiseikai General Hospital); Takayuki Hisanaga, MD (Tsukuba Medical Center Foundation); Tatsuhiko Ishihara, MD (Palliative Care Depart-
ment, Okayama Saiseikai General Hospital); Tomoyuki Iwashita, MD (Matsue City Hospital); Keisuke Kaneishi, MD, PhD (Department of Palliative Care Unit, Japan
Community Health Care Organization (JCHO) Tokyo Shinjuku Medical Center); Shohei Kawagoe, MD (Aozora Clinic); Toshiyuki Kuriyama, MD, PhD (Department of
Palliative Medicine, Wakayama Medical University Hospital Oncology Center); Takashi Maeda, MD (Department of Palliative Care, Tokyo Metropolitan Cancer and In-
fectious Disease Center, Komagome Hospital); Ichiro Mori, MD (Gratia Hospital Hospice); Nobuhisa Nakajima, MD, PhD (Department of Palliative Medicine, Graduate
School of Medicine, Tohoku University); Tomohiro Nishi, MD (Kawasaki Comprehensive Care Center, Kawasaki Municipal Ida Hospital); Hiroki Sakurai, MD (Depart-
ment of Palliative Care, St. Luke’s International Hospital); Satofumi Shimoyama, MD, PhD (Department of Palliative Care, Aichi Cancer Center Hospital); Takuya Shinjo,
MD (Shinjo Clinic); Hiroto Shirayama, MD (Iryouhoujinn Takumikai Osaka Kita Homecare Clinic); Takeshi Yamada, MD, PhD (Department of Gastrointestinal and
Hepato-Biliary-Pancreatic Surgery, Nippon Medical School); Shigeki Ono, MD (Division of Palliative Medicine, Shizuoka Cancer Center Hospital); Taketoshi Ozawa, MD,
PhD (Megumi Zaitaku Clinic); Ryo Yamamoto, MD (Department of Palliative Medicine, Saku Central Hospital Advanced Care Center); Naoki Yamamoto, MD, PhD
(Department of Primary Care Service, Shinsei Hospital); Hideki Shishido, MD (Shishido Internal Medicine Clinic); Mie Shimizu, MD (Saiseikai Matsusaka General Hospi-
tal); Masanori Kawahara, MD PhD (Soshukai Okabe Clinic); Shigeru Aoki, MD (Sakanoue Family Clinic); Akira Demizu, MD (Demizu Clinic); Masahiro Goshima, MD, PhD
(Homecare Clinic Kobe); Keiji Goto, MD (Himawari Zaitaku Clinic); Yasuaki Gyoda, MD, PhD (Kanamecyo Home Care Clinic); Jun Hamano, MD (Division of Clinical
Medicine, Faculty of Medicine, University of Tsukuba); Kotaro Hashimoto, MD (Fukushima Home Palliative Care Clinic); Sen Otomo, MD (Shonan International Village
Clinic); Masako Sekimoto, MD (Sekimoto Clinic); Takemi Shibata, MD (Kanwakeakurinikku Eniwa); Yuka Sugimoto, MD (Sugimoto Homecare Clinic); Mikako Matsunaga,
MD (Senri Pain Clinic); Yukihiko Takeda, MD (Hidamari Clinic); Takeshi Sasara, MD (Yuuaikai Nanbu Hospital); and Jun Nagayama, MD (Peace Clinic Nakai).

DOI: 10.1002/cncr.29844, Received: October 22, 2015; Revised: November 23, 2015; Accepted: November 24, 2015, Published online March 28, 2016 in Wiley
Online Library (wileyonlinelibrary.com)

Cancer May 1, 2016 1453

Original Article
hazards analysis revealed that the place of death had a significant influence on the survival time in both unadjusted (hazard ratio
[HR], 0.86; 95% CI, 0.78-0.96; P < .01) and adjusted models (HR, 0.87; 95% CI, 0.77-0.97; P 5 .01). CONCLUSIONS: In comparison with
cancer patients who died in a hospital, cancer patients who died at home had similar or longer survival. Cancer 2016;122:1453-60.
C 2016 American Cancer Society.
V
KEYWORDS: advanced cancer patients, place of death, Prognosis in Palliative Care Study (PiPS) predictor model, survival time, type
of palliative care.
INTRODUCTION
Dying in the preferred place is one of the most important
factors for a good death.1 More than half of all people
would prefer to be cared for and die at home, and the
quality of death and dying is actually superior at home
versus a hospital.2-8
However, death at home is not achieved in many
countries or is achieved only at a very late stage of the dis-
ease for multiple reasons, such as a lack of caregivers,
insufficient resources, and unpreparedness of the patient
and family. 9,10 One concern is that the quality of medical
treatment provided at home will be inferior to that given
in a hospital and that survival might be shortened.11-13
Although a preliminary study revealed that patients
receiving home-based palliative care had significantly lon-
ger survival than those receiving hospital-based palliative
care,14 whether the survival time is actually different
according to the place of death remains unclear. There-
fore, clarification of whether the survival time differs with
the place of death (ie, home vs hospital) is important to
ensure adequate timing in the use of home-based pallia-
tive care services.
Nonetheless, very few studies have investigated
potential differences in the survival time of patients with
advanced cancer dying at home or in a hospital. Also, a
previous study was limited by a lack of adjustment for suf-
ficient prognostic factors and was conducted at a single
14
center with a small number of patients.
Accordingly, the primary aim of this secondary anal-
ysis of a Japanese prospective, multicenter study was to
investigate the potential difference in the survival time
between cancer patients dying at home and cancer
patients dying in a hospital through an assessment of a
large sample with appropriate adjustments for prognostic
factors.
MATERIALS AND METHODS
This study was a secondary analysis of the Japan Prognos-
tic Assessment Tools Validation study, which was a multi-
center, prospective cohort study performed to investigate
the feasibility and accuracy of existing prognostic tools.
The methodology of the Japan Prognostic Assessment
1454
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Tools Validation study has been reported in detail in else-
where.15-19 It was conducted at 58 palliative care services
in Japan from September 2012 through April 2014. The
participating services included 19 hospital palliative care
teams, 16 palliative care units, and 23 home-based pallia-
tive care services. The physician who was primarily re-
sponsible for each patient performed an evaluation and
recorded all outcome measures on the day of admission
and followed the patient until death or 6 months after
enrollment.
This study was conducted in accordance with the
ethical standards of the Declaration of Helsinki and the
ethical guidelines for epidemiological research presented
by the Ministry of Health, Labor, and Welfare of Japan.
The institutional review boards of all participating services
approved this study.
Patients
Eligible patients were enrolled consecutively as they were
referred to the participating services during the study pe-
riod. All services were asked to evaluate and collect data
on a specific number of patients (eg, 20, 40, 60, 80, or
100) according to the size of each service. Patients were el-
igible for the study if they were adults (20 years old or
older), had locally advanced or metastatic cancer (includ-
ing hematopoietic neoplasms), and had been admitted to
a palliative care unit, had been referred to a hospital pallia-
tive care team, or were receiving home-based palliative
care. The common reasons for patients being admitted to
a palliative care unit or being referred for palliative care
were symptom control (eg, pain, delirium, and dyspnea)
and care during dying.
Measurements
The survival time was defined as the period from the day
of referral to the date of death. If patients survived for >6
months after enrollment, the survival time was defined as
180 days, and they were censored at that time.
To adjust for background factors with a potential
influence on the survival time, we obtained data on the
day of referral to formulate modified Prognosis in Pallia-
tive Care Study predictor model A (PiPS-A).15,16 The
Cancer May 1, 2016
 Survival Time and Place of Death/Hamano et al

TABLE 1. Patient Characteristics

All Patients Hospital Deaths Home Deaths

Characteristic (n 5 2069) (n 5 1607) (n 5 462)

Age, mean 6 standard deviation, y 69.4 6 12.6 68.5 6 12.5 72.3 6 12.6
Male sex, No. (%) 1207 (58.3) 912 (56.8) 295 (63.9)
Site of primary cancer, No. (%)
Lung 434 (21.0) 338 (21.0) 96 (20.8)
Gastrointestinal 989 (47.8) 753 (46.9) 236 (51.1)

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Gynecological 116 (5.6) 99 (6.2) 17 (3.7)
Urogenital 134 (6.5) 100 (6.2) 34 (7.4)
Breast 100 (4.8) 83 (5.2) 17 (3.7)
Other 247 (11.9) 201 (12.5) 46 (10.0)
Metastatic site, No. (%)
Anywhere 1672 (80.8) 1315 (81.8) 357 (77.3)
Liver 785 (37.9) 613 (38.1) 172 (37.2)
Bone 590 (28.5) 480 (29.9) 110 (23.8)
Lung 707 (34.2) 564 (35.1) 143 (31.0)
Central nervous system 243 (11.7) 199 (12.4) 44 (9.5)
Dyspnea, No. (%) 649 (31.4) 528 (32.9) 121 (26.2)
Anorexia, No. (%) 1635 (79.0) 1257 (78.2) 378 (81.8)
Dysphagia, No. (%) 546 (26.4) 431 (26.8) 115 (24.9)
Fatigue, No. (%) 1541 (74.5) 1193 (74.2) 348 (75.3)
Weight loss in previous month, No. (%) 1440 (69.6) 1095 (68.1) 345 (74.7)
Delirium, No. (%) 468 (22.6) 398 (24.8) 70 (15.2)
Abbreviated Mental Test rating by physician  3, No. (%) 574 (27.7) 462 (28.7) 112 (24.2)
Eastern Cooperative Oncology Group performance status, No. (%)
0-1 142 (6.9) 110 (6.8) 32 (6.9)
2 353 (17.1) 282 (17.5) 71 (15.4)
3 788 (38.1) 617 (38.4) 171 (37.0)
4 784 (37.9) 596 (37.1) 188 (40.7)
Global health, No. (%)
1 (extremely poor) 239 (11.6) 190 (11.8) 49 (10.6)
2 544 (26.3) 432 (26.9) 112 (24.2)
3 727 (35.1) 555 (34.5) 172 (37.2)
4 339 (16.4) 264 (16.4) 75 (16.2)
5-7 (normal health) 214 (10.3) 164 (10.2) 50 (10.8)
Anticancer therapy, No. (%)
Chemotherapy 406 (19.6) 338 (21.0) 68 (14.7)
Hormone therapy 21 (1.0) 16 (1.0) 5 (1.1)
Radiotherapy 87 (4.2) 70 (4.4) 17 (3.7)

rationale for using the modified PiPS-A as the principal
adjustment factor was that it was a superior predictor in
comparison with other prediction scores investigated,
including the Palliative Prognostic Score,20 the Delirium-
Palliative Prognostic Score,21 and the Palliative Prognos-
tic Index.15,22 The modified PiPS-A includes the follow-
ing: Abbreviated Mental Test score, pulse rate, anorexia,
dyspnea, dysphasia, fatigue, weight loss during the last
month, Eastern Cooperative Oncology Group perform-
ance status, and global health status (which is rated on a
specific 7-point scale used in the original study: [1]
extremely poor health to [7] normal health). Symptoms
were recorded as being either present or absent. Cognitive
status was evaluated according to the Abbreviated Mental
Test score used in the original Prognosis in Palliative Care
Study models, as reported by Gwilliam et al.23 In the cur-
rent study, cognitive status was rated as absent if the score
on the Abbreviated Mental Test was 3 points or as pres-
ent if the score was >3 points (scoring was performed by a
physician without interviewing the patient).
We also recorded the demographic and clinical char-
acteristics of the participants, including the age, sex, place
of palliative care, palliative performance scales,24 site of
the primary cancer and metastatic disease, anticancer ther-
apy (including chemotherapy, hormone therapy, and
radiotherapy), presence of delirium (according to Diag-
nostic and Statistical Manual of Mental Disorders, 4th edi-
tion25, and use of life-sustaining treatment (ie, parenteral
hydration during the 48 to 72 hours before death and an-
tibiotic therapy during the initial 3-week period after
enrollment).
Statistical Analysis
Our main interest was the potential difference in the sur-
vival time between patients who died at home and patients
who died in a hospital, so patients dying at home were

Cancer May 1, 2016 1455

Original Article
TABLE 2. Type of Palliative Care and Place of
Death
Hospital Home
Deaths, Deaths, Total,
No. (%) No. (%) No.
Hospital-based palliative 1507 (95.3) 75 (4.7) 1582
care service
Home-based palliative 100 (20.5) 387 (79.5) 487
care service
Total 1607 462 2069
compared with those dying in a hospital, and we excluded
patients dying at long-term care facilities. We also per-
formed analyses based on the type of palliative care:
hospital-based palliative care (palliative care team and pal-
liative care unit) versus home-based palliative care.
To adjust for patient background factors with a
potential influence on the survival time, we compared sur-
vival times for the following modified PiPS-A survival
groups: patients surviving for days (0-13 days), weeks (14-
55 days), and months (>55 days). We plotted survival
curves with the Kaplan-Meier method and compared the
survival times of patients who died at home and those
who died in a hospital. In addition, we conducted a multi-
variate analysis and calculated the hazard ratio (HR) and
95% confidence interval (CI) with Cox regression analysis
with adjustments for age (per decade), sex, primary cancer
site, presence of metastasis, anticancer therapy within 1
month, presence of delirium, and palliative performance
scale category (10-20, 30-50, or  60).
In addition, we compared the use of life-sustaining
treatment before death (parenteral hydration during the
48-72 hours before death and antibiotic therapy during
the initial 3-week period after enrollment) between the
places of death and between the types of care.
Significance was accepted at P < .05, and analyses
were conducted with SPSS-J software (version 22.0; IBM,
Tokyo, Japan).
RESULTS
A total of 2426 subjects were recruited in the original
study. Among them, 357 patients were excluded: 63
patients with data missing for the date of death, 14
patients who died at long-term care facilities, and 280
patients for whom the place of death was unknown.
Among the remaining 2069 patients who were analyzed,
1607 died in a hospital, and 462 died at home.
Patient characteristics are summarized in Table 1.
The mean age was 69.4 years. The gastrointestinal tract
was the most frequent site of the primary cancer, and this
1456
was followed by respiratory tract/intrathoracic cancer.
Among the 1582 patients who received hospital-based
palliative care, 1507 actually died in a hospital, and 75
died at home, whereas among the 487 patients receiving
home-based palliative care, 100 died in a hospital, and
387 died at home (Table 2).
Difference in the Survival Time Between
Printed by [American Cancer Society Journals - 187.086.077.247 - /doi/epdf/10.1002/cncr.29844] at [28/04/2021].
Patients Dying at Home and Patients Dying in a
Hospital
As shown in Figure 1, the survival time of patients who
died at home was significantly longer than the survival
time of those who died in a hospital in the days’ prognosis
group (estimated median survival time, 13 days [95% CI,
10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days];
P 5 .006) and in the weeks’ prognosis group (36 days
[95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5
days]; P 5 .007) as defined by PiPS-A. However, no sig-
nificant difference was identified for the months’ progno-
sis group (59 days [95% CI, 47.5-70.5 days] vs 62 days
[95% CI, 55.1-68.9 days]; P 5 .925).
Cox proportional hazards analysis revealed that the
place of death had a significant influence on the survival
time in the unadjusted model (HR, 0.86 [95% CI, 0.78-
0.96]; P < .01) and in the adjusted model (HR, 0.87
[95% CI, 0.77-0.97]; P 5 .01). The other factors with a
significant influence on the survival time were age (per
decade), sex, palliative performance scale category, lung
cancer, gastrointestinal cancer, breast cancer, delirium,
and modified PiPS-A group (Table 3).
Difference in the Survival Time Between
Patients Receiving Hospital-Based Palliative
Care and Patients Receiving Home-Based
Palliative Care
As shown in Figure 2, the survival time of patients who
received home-based palliative care was significantly lon-
ger than the survival time of those who received hospital-
based palliative care in the days’ prognosis group as
defined by PiPS-A (estimated median survival time, 13
days [95% CI, 10.4-15.6 days] vs 10 days [95% CI, 8.9-
11.1 days]; P 5 .039). However, no significant difference
was identified in the weeks’ prognosis group (34 days
[95% CI, 29.1-38.9 days] vs 29 days [95% CI, 30.0-36.0
days]; P 5 .064) or in the months’ prognosis group (65
days [95% CI, 54.1-75.9 days] vs 60 days [95% CI, 51.6-
68.4 days]; P 5 .33).
Cox proportional hazards analysis revealed that the
type of care had a significant influence on the survival
time in the unadjusted model (HR, 0.84 [95% CI, 0.76-
0.93]; P 5 .001) and in the adjusted model (HR, 0.91
Cancer May 1, 2016

Figure 1. Kaplan-Meier survival curves stratified by the place of death for 3 groups defined according to Prognosis in Palliative
Care Study predictor model A (PiPS-A): days’ group (0-13 days), weeks’ group (14-55 days), and months’ group (56 days).
[95% CI, 0.82-1.02]; P 5 .108). The other significant
factors for survival time were age (per decade), sex, pallia-
tive performance scale category, lung cancer, gastrointesti-
nal cancer, breast cancer, delirium, and modified PiPS-A
group (Table 3).
Differences in Life-Sustaining Treatment Before
Death
The percentages of patients who received parenteral
hydration before death and received antibiotics were sig-
nificantly higher among those who died in a hospital ver-
sus those who died at home (Table 4).
DISCUSSION
Findings
To the best of our knowledge, this is the first large-scale,
prospective, multicenter study to explore the potential
association between the place of death and the survival
time.
Cancer May 1, 2016
Survival Time and Place of Death/Hamano et al
Printed by [American Cancer Society Journals - 187.086.077.247 - /doi/epdf/10.1002/cncr.29844] at [28/04/2021].
The most important finding of this study is that
patients who died at home had a survival time similar to
or significantly longer than that of patients who died in a
hospital after adjustments for background factors with the
proven prognostic classification Prognosis in Palliative
Care Study model. This finding is consistent with the
results of a preliminary study showing that patients receiv-
ing home-based palliative care had significantly longer
survival than those receiving hospital-based palliative care
with a median survival time of 67 days versus 33 days.14
Although that single-center study used only 5 factors for
adjustments, the current multicenter study compared sur-
vival with a validated prognostic classification. To con-
firm whether the place of death influences the survival
time, a randomized controlled trial is the most robust type
of clinical research, but randomizing the place of death is
practically impossible and unethical. Therefore, well-
designed observational studies that compare survival by
matching patient background factors can provide the best
available evidence.
1457
Original Article

TABLE 3. Cox Proportional Hazards Analysis of the Survival Time and the Place of Death

Place of Death Type Of Palliative Care

Hazard 95% Confidence Hazard 95% Confidence

Ratio Interval P Ratio Interval P

Unadjusted model: home 0.86 a 0.78-0.96 <.01 0.84 b 0.76-0.93 .001

Adjusted model c
a b

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Home 0.87 0.77-0.97 .01 0.91 0.82-1.02 .108
Age (per decade) 0.96 0.93-1.00 <.05 0.96 0.93-1.00 .046
Sex 0.86 0.78-0.95 <.01 0.86 0.78-0.95 .004
Palliative performance status
60 <.001 <.001
30-50 1.42 1.24-1.63 <.001 1.41 1.23-1.62 <.001
10-20 2.94 2.43-3.56 <.001 2.95 2.44-3.57 <.001
Site of primary cancer
Other <.001 .003
Lung 1.27 1.08-1.50 <.01 1.26 1.07-1.49 .006
Gastrointestinal 1.36 1.17-1.58 <.001 1.35 1.16-1.57 <.001
Gynecological 1.17 0.92-1.45 .20 1.17 0.92-1.48 .21
Urogenital 1.26 1.00-1.58 .05 1.25 1.00-1.57 .053
Breast 1.50 1.16-1.94 <.01 1.50 1.16-1.93 .002
Presence of metastasis 1.01 0.90-1.14 .83 1.01 0.90-1.15 .823
Presence of anticancer therapy 0.92 0.81-1.03 .15 0.92 0.81-1.03 .15
Presence of delirium 1.20 1.05-1.36 <.01 1.21 1.06-1.37 .004
Modified PiPS-A
Months <.001 <.001
Weeks 1.44 1.26-1.65 <.001 1.43 1.25-1.64 <.001
Days 2.24 1.86-2.69 <.001 2.20 1.83-2.64 <.001

Abbreviation: PiPS-A, Prognosis in Palliative Care Study predictor model A.

a
Home death.
b
Home-based palliative care service.
c
Adjusted by age, sex, palliative performance status category, site of primary cancer, chemotherapy, any metastasis, delirium, and PiPS-A group.

Implications and Generalizations
Our findings demonstrate that home death does not have
a negative influence on the survival of cancer patients.
Thus, the noninferiority of the survival time for patients
dying at home suggests that an oncologist should not hesi-
tate to refer patients for home-based palliative care simply
because less medical treatment may be provided.
Although patients with home deaths and home-
based palliative care had similar or significantly longer
survival in comparison with patients with hospital deaths
and hospital-based palliative care, it is interesting that life-
sustaining treatment (parenteral hydration and antibiot-
ics) was provided for a significantly higher percentage of
patients with hospital deaths and hospital-based palliative
care. A possible reason for the finding that home death
had no measurable negative influence on survival despite
less use of parenteral hydration and antibiotics is that
these treatments were not effective for prolonging survival
in the patient population of this study. This is consistent
with the results of a previous randomized controlled
study, which revealed that parenteral hydration had no
measurable effect on the survival of patients with
advanced cancer (median survival time, 21 days [95% CI,
13-29 days] for the hydration group vs 15 days [95% CI,
12-18 days] for the placebo group).26 Moreover, a previ-
ous prospective study revealed no significant difference in
the survival of cancer patients who received antimicrobial
therapy versus patients who did not receive it (median sur-
vival, 29 days for patients with antimicrobial therapy vs
31 days for patients without antimicrobial therapy).27
Furthermore, this previous study found no significant dif-
ference in the survival of cancer patients with a diagnosed
infection versus patients without an infection (median
survival, 29 days for patients with infections vs 31 days for
patients without infections).27 These points need to be
explored further in future studies.
Strengths and Limitations
The strengths of this study were its large sample size, the
participation of institutions across the country, and the
use of a valid prognostic classification system. The current
study also had some limitations. First, data on 63 patients
(2.6%) were excluded because they had been lost to
follow-up or the date of death was missing. However, this
proportion was small, and thus we believe that our conclu-
sions remain unaffected. Second, we could not adjust for

1458 Cancer May 1, 2016

 Survival Time and Place of Death/Hamano et al

Printed by [American Cancer Society Journals - 187.086.077.247 - /doi/epdf/10.1002/cncr.29844] at [28/04/2021].

Figure 2. Kaplan-Meier survival curves stratified by the type of palliative care for 3 groups defined according to Prognosis in Pallia-
tive Care Study predictor model A (PiPS-A): days’ group (0-13 days), weeks’ group (14-55 days), and months’ group (56 days).

TABLE 4. Life-Sustaining Treatment Before Death

Hospital Home Hospital-Based Home-Based

Deaths, % Deaths, % P Palliative Care, % Palliative Care, % P

Parenteral hydration during 48-72 h before death

None 32.1 75.5 <.001 32.6 71.0 <.001
<1 L 57.2 22.4 56.8 25.8
1 L 10.7 2.1 10.6 3.1
Antibiotics during 3 wk after enrollment 19.9 13.9 .004 20.6 12.2 <.001

residual confounding primary predictors or the influence In conclusion, cancer patients who died at home had
on survival of unmeasured covariates (eg, symptom sever- similar or longer survival in comparison with those who
ity, disease progression, family support, availability of pal- died in a hospital.
liative care services, and patient and family preferences for
the place of death). Third, we recognize that patients who FUNDING SUPPORT
were referred for home-based palliative care might be This work was supported in part by the National Cancer Center
inherently different from those referred for hospital-based Research and Development Fund (25-A-22). All researchers were
care, although all known confounding factors were suc- independent of the funder.
cessfully adjusted. Finally, not all medical treatments were
recorded, and an exploration of the potential effect of the CONFLICT OF INTEREST DISCLOSURES
place of death on survival needs further investigation. The authors made no disclosures.

Cancer May 1, 2016 1459

Original Article
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