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Preventive drugs overprescribed for patients with advanced cancer
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Older patients with progressive and life-limiting cancer often are prescribed preventive medications that likely will have little clinical benefit while increasing out-of-pocket costs in the last year of life, according to a retrospective study published in Cancer.
Preventive drug costs for patients varied based on the type of cancer, investigators found.
“Polypharmacy within the context of advanced cancer also raises important questions from a clinical and ethical viewpoint,” Lucas Morin, MS, a doctoral student at the Aging Research Center at Karolinska Institute in Stockholm, and colleagues wrote. “As cancer progresses and the prognosis worsens, the net benefit of each additional medicine gradually decreases while the risk [for] harm increases. This ‘law of diminishing returns’ makes the continuation or initiation of long-term treatments particularly questionable for older patients with advanced cancer.”
Preventive drugs — such antihypertensives, statins and mineral supplements — typically take years to yield benefits. This raises questions about the efficacy of new prescriptions for patients with advanced cancer.
Morin and colleagues used national registry data to conduct a retrospective, cohort-based study to evaluate the frequency with which preventive drugs were prescribed in the last year of life to older patients in Sweden who died of cancer between 2007 and 2013. Researchers also evaluated the associated costs of these prescriptions, plus possible variations according to cancer type.
The analysis included 151,201 patients aged 65 years or older (mean age, 81.3 years; standard deviations, 8.1 years) with an established solid cancer diagnosis during the last 2 years of life.
The study excluded patients without a drug prescription history in the last 6 months of life, as well as those who had a simultaneous hematologic malignancy.
Results showed the mean number of drugs prescribed to these patients increased during their last year of life from 6.9 to 10.1 (mean difference, 2.1; 95% CI, 2-2.2).
Preventive medications accounted for approximately 20% of total prescribed medications patients took throughout their last year of life. The percentage of older adults who continued therapy with preventive medications until the final month of life ranged from 56.6% for bisphosphonates, 65% for vitamins and statins, and more than 80% for beta-blockers, insulin, and folic acid or vitamin B12.
Further, patients often initiated new therapies during their final year of life. More than one-quarter (28.2%) of patients began antithrombotic agents, whereas 23.2% began medication for high blood pressure and 4.9% began treatment with statins.
Median drug costs during the final year of life were $1,482 (interquartile range [IQR], $700-$2,896) per person.
Preventive therapies accounted for a mean $213 (IQR, $77-$490) of that per-person cost. Costs were highest for patients who died of pancreatic cancer, breast cancer or gynecologic cancers.
“The frequent continuation of long-term preventive drugs is indicative of insufficient deprescribing strategies at the end of life,” Morin and colleagues wrote. “Preventive medicines are not necessarily inappropriate at the end of life, because some may have palliative indications to avert distressing symptoms or to avoid serious complications. However, the large percentage of older adults with cancer who continue to receive statins, antihypertensives, and vitamins and mineral supplements throughout the last year of life does suggest the existence of routine-based prescribing practices that contribute to low-value care.”
The investigators noted potential study limitations, including the potential for retrospective studies of deceased individuals to be subject to confounding-by-indication bias.
Also, the data did not allow for assessment of whether patients took all drugs prescribed, or whether dose modifications were made near the end of life. In addition, the study population was based in Sweden, which has a universal health care system; therefore, the results may not be applicable to other populations with different health care delivery structures.
“The current study finding that older adults with cancers with a poor prognosis (eg, those of the brain, lung, liver or pancreas) were just as likely as those with less aggressive disease to use preventive drugs during their last month of life suggests that there is room for deprescribing,” Morin and colleagues wrote. “The use of preventive drugs should be reconsidered in light of the patient’s goals of care, values and preferences. Reducing the therapeutic burden in individuals with advanced cancer has the potential to not only reduce unnecessary adverse effects and improve patient quality of life, but also to reduce the financial burden for patients.” – by Drew Amorosi
Disclosure: The authors report no relevant financial disclosures.
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