Date of Award

January 2016

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Shi-Yi Wang


Background: Depression has adverse effects on health outcomes and the quality of end-of-life care among cancer patients. However, overly aggressive EOL care can result in high costs and may not be consistent with patient preferences or linked to better health. As such, there is rising interest in identifying the associations between depression and care quality for cancer patients. This study investigates whether depression is associated with EOL care intensity among elderly individuals with cancer.

Methods: Utilizing the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified decedents aged 66 years or older either with pre-cancer depression, post-cancer depression, or no depression at all. All participants were diagnosed with cancer from 2004-2011 and died within 3 years as a result of cancer. Using hierarchical generalized linear models, we determined the associations of pre- and post-cancer depression on EOL care intensity, adjusting for sociodemographic and clinical characteristics.

Results: Our sample consisted of 84,947 Medicare beneficiaries, of whom 5,072 (6%) had pre-cancer depression and 6,677 (7.9%) had post-cancer depression. Compared to participants without depression, those with pre-cancer depression were significantly less likely to have repeated hospitalizations (adjusted odds ratio [AOR] = 0.91, 95% confidence interval [CI] = 0.83-0.99) or emergency department visits (AOR = 0.89, 95% CI = 0.83-0.94), experience in-hospital death (AOR = 0.83, 95% CI = 0.77-0.89), and receive intensive care unit services (AOR = 0.86, 95% CI = 0.79-0.93) or late chemotherapy (AOR = 0.83, 95% CI = 0.70-0.99), and more likely to use hospice care (AOR = 1.20, 95% CI = 1.12-1.28). Participants with post-cancer depression had similar care intensity patterns as those with pre-cancer depression, but were insignificantly more likely to have repeat hospitalizations than those without depression (AOR = 1.04, 95% CI = 0.97-1.12).

Conclusions: Participants with pre- or post-cancer depression were less likely to receive aggressive EOL care than those without depression. Our findings suggest understanding the mechanisms that lead to these patterns may enhance EOL care quality for patients with cancer. Accurate screening and treatment for depressed patients in addition to earlier communication and initiation of hospice for all cancer patients can help promote palliative care.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/06/2018