Systemic anticancer treatment at end of life shifts to immunotherapy, still raises concern
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Increased awareness of the quality-of-life harm and financial burden associated with continued cancer treatment at the end of a patient’s life has led professional societies to promote reduced systemic anticancer therapy at this stage.
However, a study published in JAMA Oncology showed use of aggressive cancer treatment at the end of life has not decreased, but rather shifted from chemotherapy to immunotherapy.
“What I have seen in my clinical practice is that, with the prevalence of more and more targeted immunotherapies, there is the perception that these treatments are less toxic,” Kerin Adelson, MD, associate professor of medicine, chief quality officer and deputy chief medical officer for Yale Cancer Center and Smilow Cancer Hospital, told Healio. “However, I see a pattern of patients who are really beginning to decline being offered targeted therapies and immunotherapies as a sort of ‘Hail Mary’ or last-ditch effort. These patients are much less likely to transition to hospice care because they’re hoping for that miracle.”
Adelson and colleagues reviewed the Flatiron Health electronic health record database to evaluate treatment patterns of adults with cancer who received systemic therapy and died within 4 years of diagnosis. At the start of the study period in 2015 and the end of the period in 2019, results showed no difference in rates of treatment within 30 days of death (39%) and within 14 days of death (17%). Although use of chemotherapy alone decreased from 26% in 2015 to 16% in 2019, immunotherapy use increased from 5% to 18%.
Adelson and study co-author Maureen E. Canavan, PhD, MPH, associate research scientist in internal medicine and affiliated faculty at Yale Institute for Global Health, discussed their study’s findings and encouraged societal “soul searching” in terms of health care priorities and incentives.
Healio: What prompted you to conduct this study?
Canavan: Clinical experience motivated us to look at this at a national level. We had hypothesized that we would see declines in chemotherapy due to the 2012 ASCO/National Quality Forum regulation promoting decreased use of chemotherapy at the end of life. What we actually saw was that although rates of chemotherapy alone declined from 2015 to 2019, the overall use of systemic anticancer therapy remained constant. So, despite the decrease in chemotherapy, rates of immunotherapies and targeted therapies increased. This promoted the idea that we need to identify whether these newer therapies cause the same challenges to both the patient and caregivers in terms of increased acute care use. Immunotherapy is very costly, so the financial toxicity is still there. The question is, are we still facing that challenge of not giving these patients an early enough transition to palliative care and a high-quality death?
Healio: Why has this pattern of aggressive treatment at the end of life continued in the form of immunotherapy use?
Adelson: Oncologists are always excited by new treatments, and as they go through training, they’re taught to fight cancer and treat cancer. It’s hard for many to recognize that the treatments perhaps aren’t working, and to then initiate a subtle, artful goals-of-care conversation that recognizes the patient’s worsening prognosis and elucidates how that patient wants to spend the end of their life. I’ve done plenty of qualitative research in this space, and I’ve found that oncologists worry about taking away hope, causing harm or causing distress. These conversations are challenging and many, many clinicians don’t feel comfortable or have the skill set they need to do it early enough and well enough. I always say that the goals-of-care conversation is the lowest cost, highest impact intervention oncologists can make.
There is also an issue with our health system from a national perspective, in terms of what we are incentivizing with Medicare and commercial insurance coverage. We pay for systemic therapy — nobody stops you from giving an $18,000 dose of pembrolizumab. Yet the hospice benefit is totally inadequate, and patients don’t get enough care in the home to support them as they move in a palliative direction. Medicare doesn’t pay for much at all, and many, many families cannot afford to provide the 24/7 care that patients often need. So, I think we need to do some soul searching as a society and consider whether we are providing a good enough option.
Canavan: As more immunotherapies come on the market, our current system is set up to incentivize trying all the options before thinking about the patient holistically. One thing we are hoping to do with some of our future research is to look at the cost effects of these acute care utilizations associated with immunotherapy at the end of life. We want to take that evidence-based approach to show the best way to support our patients and their families and to make sure that the end of a patient’s life is as high quality as it can be.
Adelson: There has been some general euphoria around immunotherapy, as well as the assumption that it is less toxic. Many oncologists don’t see the direct harm. So, we need to show that continuing this pattern of care can lead to the same negative results as aggressive chemotherapy at the end of life — hospitalization, ED visits and an increased likelihood of a medicalized death, rather than a peaceful death in one’s home. So, that’s the next question we will have to demonstrate — that yes, this pattern can also cause harm.
For more information:
Kerin Adelson, MD, can be reached at Smilow Cancer Hospital, 20 York St., New Haven, CT 06510; email: kerin.adelson@yale.edu.
Maureen E. Canavan, PhD, MPH, can be reached at Yale School of Medicine, 333 Cedar St., New Haven, CT 06510; email: maureen.canavan@yale.edu.
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