Nonclinical Factors Influence Use of Systemic Anticancer Therapy at End of Life

Use of systemic anticancer therapy at the end of life (EOL) varied significantly by factors unrelated to clinical characteristics, a review of more than 50,000 patients showed.

Patients who received systemic treatment 30 and 14 days before EOL were more likely to be white, commercially insured, and treated at smaller and community oncology practices. These differences were driven primarily by variations in the use of immunotherapy and targeted agents.

Rates of 30-day systemic therapy varied widely across the 150 practices included in the analysis, ranging from a low of 26 per 100 patients to a median of 38/100 to a high of 57/100, reported Kerin Adelson, MD, of the University of Texas MD Anderson Cancer Center in Houston, and co-authors in the Journal of Clinical Oncology.

“This work suggests that a complex interplay of factors beyond practice guidelines and quality benchmarks continue to drive cancer care,” the authors wrote. “Lower rates of SACT [systemic anticancer therapy] during the last weeks of life has been deemed better quality of care because continuation of treatment beyond the point of benefit is associated with higher rates of acute care use, more patient and caregiver distress, loss of opportunity for a peaceful death, and overall higher economic cost.”

The findings raise several questions that could be explored in future research:

• Is use of costly immunotherapy driven by reimbursement?
• Would evaluation of care models lead to more appropriate use of palliative and anticancer therapy?
• Are structural inequities a core or contributing factor?
• What role, if any, do communication barriers play?

The authors of an accompanying editorial placed much of the blame on “the role of commercial insurance in paying the high prices of SACTs.”

“Although insurance coverage of SACTs would seem, on the face of it, to benefit patients, evidence points to the harms associated with this practice at the end of life,” asserted Holly G. Prigerson, PhD, of Weill Cornell Medicine, and Alfred I. Neugut, MD, PhD, of the Vagelos College of Physicians and Surgeons of Columbia University, both in New York City.

“Since 2012, there has been a shift from cytotoxic chemotherapies to the increasing use of checkpoint inhibitors at the EOL — a worrisome development in light of evidence that many if not most hospitalized patients who receive checkpoint inhibitors die shortly thereafter … thus enduring the burdens it imposes without realizing much, if any, of its benefits,” they wrote. “Widespread enthusiasm for the benefit of chemoimmunotherapy in many newly diagnosed patients appears to be misplaced and potentially harmful in those near the EOL.”

Noting the factors associated with increased use of systemic anticancer therapies in the study, Prigerson and Neugut pointed out that “the evidence that economic pressures drive the use of SACTs in patients with cancer close to death suggests that changes in reimbursement and payment incentives may prove promising approaches to counter this trend.”

The finding of race-associated differences in use of systemic anticancer therapies “suggests the need to address implicit racial bias in oncology training and practice and that doing so might promote understanding of the pros and cons of EOL treatments while building trust in and enhancing receptivity to oncologist treatment recommendations,” they added.

According to Adelson and colleagues, the study had its genesis in evidence that use of systemic anticancer therapies at EOL is “futile and is highly correlated with EOL emergency department, hospital and intensive care unit utilization, late transition to hospice, death in the acute care setting, and higher costs.”

They previously reported no change in trends for systemic anticancer therapy use at EOL from 2015 to 2019, but a shift from cytotoxic therapy to checkpoint inhibitors, particularly among patients with poor performance status.

To get a better understanding of factors contributing to use of systemic anticancer therapy at EOL, Adelson and colleagues analyzed electronic health record-derived data for 53,791 patients who received care in 150 oncology practices from January 2015 through January 2020. This included 19,837 patients who received systemic treatment within 30 days of death. Adelson and colleagues analyzed both 30- and 14-day use of systemic anticancer therapy.

The results showed that white patients were significantly more likely than Black patients to receive systemic anticancer therapy within 30 days (36.6% vs 32.7%, P<0.001) and 14 days (15.7% vs 13.6%, P<0.001) of death. Significantly more patients with commercial insurance received systemic anticancer therapy within 30 days of death (43.3%) versus those with Medicare (37.3%) or Medicaid (37.0%) coverage. The same was true for 14-day use.

Patients treated at community oncology practices were more likely to receive EOL therapy within 30 days of death as compared with patients treated at academic centers (37% vs 34%, P<0.001). Patients with higher (worse) Eastern Cooperative Oncology Group (ECOG) performance status scores were less likely to receive EOL systemic treatment at 30 and 14 days, but patients with unspecified performance status had the highest rate of systemic anticancer therapy use (43.1% vs 39.9% for ECOG of 0, P<0.001).

After adjustment for patient factors, practice-level variation in use of systemic anticancer therapy at EOL remained statistically significant at 30 and 14 days.