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Use of Systemic Therapy at the End of Life in Patients With Cancer: Effect of Approval of Immunotherapies


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In a study reported in JCO Oncology Practice, Khaki et al found that although the use of anticancer systemic therapy during the last 30 days of life in patients with cancer has decreased overall since the first approval of a PD-1 immune checkpoint inhibitor, the use of PD-1 or PD-L1 inhibitors during the last 30 days of life has increased.

Study Details

The study involved data from the Western Washington Cancer Surveillance System (covering residents of 13 counties of western Washington state) linked to commercial and Medicare insurance. Systemic therapy use in the last 30 days of life in patients with advanced solid tumors was analyzed for the 4 years preceding (pre–immune checkpoint inhibitor period; January 1, 2011, to September 4, 2014) and 4 years after (post–immune checkpoint inhibitor period; September 5, 2014, to December 31, 2018) approval of the first PD-1 immune checkpoint inhibitor on September 4, 2014. Use of PD-1/PD-L1 immune checkpoint inhibitor was assessed for the post–immune checkpoint inhibitor period.

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Key Findings

A total of 8,871 patients were included in the analysis, of whom 3,045 died during the pre–immune checkpoint inhibitor period and 5,826 during the post–immune checkpoint inhibitor period.

Systemic therapy use in the last 30 days of life was lower in the post–immune checkpoint inhibitor vs pre–immune checkpoint inhibitor period (12.4% vs 14.4%, difference = -2.0%, 95% confidence interval [CI] = -3.5% to -0.5%; prevalence ratio [PR] = 0.86, 95% CI = 0.77–0.96).

Among the five diagnoses with an early immune checkpoint inhibitor indication, systemic therapy use during the last 30 days was more prevalent in the post–immune checkpoint inhibitor vs pre–immune checkpoint inhibitor period for melanoma (PR = 1.26), renal cell carcinoma (PR = 1.69), and head and neck squamous cell carcinoma (PR = 1.51), and less prevalent for non–small cell lung cancer (PR = 0.89) and urothelial carcinoma (PR = 0.87), although none of the differences were statistically significant.

The annual prevalence of systemic therapy use in the last 30 days of life decreased from 16.1% in 2011 to 10.4% in 2018. However, immune checkpoint inhibitor use in the last 30 days of life increased from 0% to 2.4% during the post–immune checkpoint inhibitor period. Immune checkpoint inhibitor use accounted for 23% of all systemic therapy use in the last 30 days of life in 2018 vs 1% in 2014.

Compared with patients who received non–immune checkpoint inhibitor systemic therapy during the last 30 days of life in the post–immune checkpoint inhibitor period, those who received immune checkpoint inhibitors had higher rates of one or more emergency department visits (33% vs 26%), higher rates of two or more hospital admissions (32% vs 24%), and higher total medical costs ($28,400 vs $23,900) and drug costs ($8,100 vs $2,100), with 88% of drug costs ($7,400) attributable to immune checkpoint inhibitors.

The investigators concluded, “Systemic therapy use in the last 30 days of life was lower in the period after immune checkpoint inhibitor approval. However, immune checkpoint inhibitor use rose over time and had higher utilization and costs in the last 30 days of life. Systemic therapy use in the last 30 days of life warrants monitoring, especially as more immune checkpoint inhibitor indications are approved.”

Ali Raza Khaki, MD, MS, of Stanford University School of Medicine, is the corresponding author for the JCO Oncology Practice article.

Disclosure: The study was supported by a grant from the National Cancer Institute. For full disclosures of the study authors, visit ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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