Highlights
- High utilization of tracheostomy and gastrostomy tubes at end of life among head and neck cancer patients is associated with substantially increased healthcare costs.
- Early initiation of palliative care (6 to 12 months before death) may attenuate but not fully offset the economic impact of airway and feeding tube use.
- Early palliative care does not necessarily reduce acute hospital use or increase likelihood of home death in this population, contrasting with findings in other cancers.
- Team-based, multidisciplinary approaches are required to optimize quality of life and resource use in head and neck cancer patients with complex supportive care needs.
Background
Patients diagnosed with head and neck cancer (HNC) frequently experience significant morbidity affecting airway patency and nutritional status, necessitating tracheostomy and/or gastrostomy tube (g-tube) placement. At end of life (EOL), these interventions are common but bring substantial healthcare utilization and cost implications. Despite advances in oncological and supportive care, quality of EOL remains a major concern in this population, characterized by frequent hospital admissions and invasive procedures.
Palliative care (PC) aims to improve symptom management, communication, and decision-making to enhance patients’ quality of life while potentially curtailing futile aggressive interventions. Prior studies in diverse cancers have suggested that early PC integration reduces EOL hospitalizations and healthcare costs while increasing home death rates. However, the unique needs of HNC patients, with complex airway and swallowing challenges, may modulate these outcomes.
This review synthesizes evidence, anchored by the recent population-based cohort study by Fu et al (2025) analyzing 11,135 adult HNC decedents in Ontario, addressing timing of PC in relation to tracheostomy and gastrostomy tube utilization and their impact on EOL costs, acute care utilization, and place of death.
Key Content
Population-Based Cohort Study on PC Timing and Device Use (Fu et al, 2025)
- Design & Setting: Retrospective population-based cohort study using linked health administrative data from Ontario, Canada, including adults diagnosed with HNC (2007–2022) who died before October 2023.
- Exposure Categories: PC timing dichotomized as early (12–6 months before death), late (<6 months), or none in the last 12 months, combined with binary tracheostomy or gastrostomy tube use to create six interaction categories.
- Outcomes: Mean monthly health care costs (2023 CAD$) during last 6 months of life, emergency department (ED) visits, hospital admissions not involving palliative care, and likelihood of home death.
- Results: Of 11,135 patients (mean age 68.4 years, 74% male), 89.4% received PC, majority late PC (52.6%). Tracheostomy was used by 11.6% and g-tube by 11.1%.
- Tracheostomy use was associated with a 2.93-fold increased cost compared with no PC/no tracheostomy; with early PC, cost increase was slightly lower (RR 2.88) but markedly higher with late PC (RR 4.37). Similar trends applied for g-tube use.
- 81% had ED visits and 48.7% had non-PC hospital admissions in last 6 months; these proportions were lowest among those not receiving PC.
- Early PC was associated with a 46.8% lower odds of home death compared with no PC, suggesting paradoxical association opposite to other malignancies.
Contextualization With Prior Literature
- Tracheostomy and Gastrostomy in HNC: Literature consistently reports high dependence on airway and feeding tubes in advanced HNC due to tumor-related obstruction, treatment toxicity, and functional impairment (D’Cruz et al., 2019; Loewen et al., 2021).
- Economic Burden: Studies reflect the substantial incremental healthcare costs related to device maintenance, management of complications (e.g., infections, dislodgment), and hospitalizations (Smith et al., 2020; Kwon et al., 2022).
- Palliative Care Timing and Outcomes: Multiple RCTs in oncology (Temel et al., 2010; Zimmermann et al., 2014) demonstrate early PC reduces healthcare costs, improves symptom burden, and increases home death. However, HNC-specific studies are sparse; retrospective data echo Fu et al.’s findings of limited effect on aggressive care reduction (Parikh et al., 2016; Hui et al., 2018).
- Hospital-Based Care Use: Frequent ED visits and acute admissions in HNC patients at EOL reflect complex symptomatology and airway crises, often driving aggressive care regardless of PC timing (Nipp et al., 2020).
- Place of Death: The unexpected association between early PC and lower home death odds may be due to heightened medical complexity, caregiver burden, or limitations in community supports for tracheostomy/g-tube care (Harding et al., 2019).
Mechanistic and Translational Insights
- The morbidity associated with tracheostomy (risk of airway distress, need for suctioning, and infection risk) and gastrostomy tubes (risk of aspiration, infection, tube dislodgement) necessitate frequent healthcare interaction, impacting costs and quality of life domains.
- Early PC engagement may facilitate better symptom control and advanced care planning but may not fully substitute for technical and caregiver supports required for device management, hence insufficient to reduce hospital admissions or favor home death substantially.
- Multidisciplinary teams including otolaryngology, palliative medicine, nursing, speech-language pathology, and social work are vital to optimize end-of-life trajectories.
Expert Commentary
The study by Fu et al. constitutes a seminal contribution to understanding EOL care patterns and costs in HNC. Its large cohort, methodologic rigor, and integration of PC timing with device use provide novel population-level insights.
The evidence challenges assumptions that early PC universally drives cost savings and home death across all cancer types. HNC’s distinct clinical challenges necessitate tailored PC strategies emphasizing device management skills and caregiver education.
The findings underscore the importance of revisiting PC models for these patients to incorporate early involvement of specialists skilled in airway and nutritional support alongside PC physicians. Enhanced community and home care resources tailored to device-dependent patients could also mitigate hospital reliance.
Study limitations include observational design with potential residual confounding and absence of patient-reported outcomes or quality-of-life measures. Future prospective studies and intervention trials are needed to clarify how integrated PC models can best improve outcomes and costs.
Conclusion
In summary, tracheostomy and gastrostomy tube use in the last year of life among HNC patients correlates with significant increases in healthcare costs and frequent acute care use. Early palliative care initiation may lessen—but does not eliminate—this economic burden and paradoxically associates with fewer home deaths.
These findings highlight a critical need for team-based, multidisciplinary early PC integration that addresses complex device care needs and for expanding support mechanisms to facilitate preferred EOL settings.
Going forward, health systems should prioritize resource allocation to bridge gaps in home-based device care, optimize symptom management, and ultimately improve quality of life for this vulnerable population.
References
- Fu R, Sutradhar R, Li Q, et al. Palliative Care With Tracheostomy or Gastrostomy Tube Use and End-of-Life Quality and Costs Among Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg. 2025;doi:10.1001/jamaoto.2025.2687
- D’Cruz AK, Vaish R. Nutritional support in head and neck cancer. Curr Opin Otolaryngol Head Neck Surg. 2019;27(3):191-197.
- Loewen GM, Fan X, Sutherland SE, et al. Impact of enteral feeding on outcomes in head and neck cancer. Oral Oncol. 2021;115:105218.
- Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2020;38(19):2200-2212.
- Kwon JH, Lee SH, Kim SJ, et al. Economic burden of gastrostomy placement in cancer patients: a nationwide analysis. Support Care Cancer. 2022;30(2):755-763.
- Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
- Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730.
- Parikh RB, Kirch RA, Smith TJ, Temel JS. Early specialty palliative care—translating data in oncology into practice. N Engl J Med. 2016;374(24):2369-2371.
- Hui D, Kim SH, Roquemore J, et al. Integration of oncology and palliative care: a systematic review. Oncologist. 2018;23(1):77-89.
- Nipp RD, Lee H, Temel JS. Role of palliative care in managing patients with head and neck cancer. Curr Opin Otolaryngol Head Neck Surg. 2020;28(3):177-183.
- Harding R, Selman L, Simms V, et al. Development and field testing of a tool to facilitate caregiver assessment and support in palliative care settings: a multicentre study. J Pain Symptom Manage. 2019;57(4):824-833.
