Many Patients at End of Life Still Receiving Cancer Therapy

Roxanne Nelson, RN, BSN

November 01, 2022

Despite a growing focus on reducing aggressive therapy at the end of life and integrating palliative care sooner, the use of systemic anticancer therapy in the last weeks of patients' lives has remained relatively unchanged, a new analysis revealed.

Researchers found that the use of systemic therapy at the end of life for all cancer types remained the same between 2015 and 2019; however, the type of treatment used did shift. Patients received less chemotherapy but more immunotherapy during this period.

Megan A. Mullins, PhD, MPH, who was not involved in the research, said she did not find it surprising that terminally ill patients are still receiving aggressive care.

"Cancer is often likened to a battle that must be won, and our weapons are treatment options," said Mullins, from the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.

The findings were published online in JAMA Oncology.

Previous research has shown that the use of systemic anticancer therapy at the end of life is associated with late hospice enrollment, higher costs, and potentially adverse quality and length of life. In 2012, the American Society of Clinical Oncology and the National Quality Forum developed a quality measure to help reduce the use of chemotherapy at the end of life.

But with many new targeted therapy options approved in recent years, the study authors wanted to understand whether patterns of care at the end of life have changed.

The researchers used the nationwide Flatiron Health electronic health record–derived database that incorporates information from about 280 US cancer clinics, including approximately 800 sites and more than 2 million patients. The authors identified adult patients who were diagnosed with cancer beginning in 2011 and who received treatment and died within 4 years of their diagnosis.

The primary outcome was the use of systemic anticancer therapy at 30 days and 14 days before death. The authors examined treatment rates across six common cancer types — breast, colorectal, pancreatic, non–small-cell lung, and urothelial cancers as well as renal cell carcinoma.

The team found that the rate of systemic therapy within 30 days of death across all cancer types combined remained the same in 2015 and 2019 — at 39%. Similar patterns were seen within 14 days of death — about 17% continued to receive treatment in 2015 and 2019.

The authors did observe a slight decrease in overall use of systemic therapies among patients with metastatic breast cancer, renal cell carcinoma, and colorectal cancer.

However, the type of systemic therapy changed. The use of chemotherapy declined from 26% in 2015 to 16% in 2019, while the use of immunotherapy jumped more than threefold from 5% in 2015 to 18% in 2019. The increase in immunotherapy use was most pronounced in patients with advanced non–small-cell lung cancer and urothelial cancers.

"Approval of multiple new immunotherapy agents has engendered a great replacement phenomenon, substituting immunotherapy for chemotherapy," the authors concluded.

Mullins explained that the availability of immunotherapy has further complicated this issue of aggressive end-of-life care because there is less guidance on its use and more uncertainty around who might benefit from using it.

"Stopping active treatment requires a momentum shift, and as a culture, we don't like to talk about death and our healthcare system is not set up to support timely goals of care conversations where physicians can unpack the implications of these potential treatment options," Mullins said.

Mullins reported no disclosures.

JAMA Oncol. Published online October 20, 2022. Abstract

Roxanne Nelson is a registered nurse, an award-winning medical writer who has written for many major news outlets, and a regular contributor to Medscape.

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