Findings highlight ‘desperate need’ to improve end-of-life cancer treatment
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Key takeaways:
- Anticancer treatment for adults with advanced solid tumors did not confer OS benefits compared with no therapy.
- Results provide evidence for increased use of palliative care for some advanced solid tumors.
Oncologic treatment of adults with various metastatic or advanced solid tumors may not improve OS and could be detrimental to quality of life, according to findings published in JAMA Oncology.
Individuals who had metastatic or advanced forms of renal cell carcinoma or breast, colorectal, non-small cell lung, pancreatic or urothelial cancers treated at institutions that administered the most end-of-life anticancer therapies did not gain discernable survival benefits compared with those cared for at centers that gave the fewest end-of-life treatments.
“Knowing there is no survival benefit for use of systemic therapy for patients nearing the end of life, oncologists should communicate openly about prognosis and recommend transitioning to palliative and supportive care instead of continuing systemic therapy,” Kerin B. Adelson, MD, chief quality and value officer and professor at The University of Texas MD Anderson Cancer Center, told Healio.
Background
Previous studies have indicated patients treated with systemic anticancer therapies at the end of their lives can often spend their final days worse off, according to background information provided by researchers.
“When oncologists give treatments to patients with very advanced cancer who are approaching the end of life, they hope it will help the patient live longer,” Adelson said. “Unfortunately, patients who get cancer-directed therapy near the end of life are more likely to spend their last weeks of life in the hospital, visit emergency departments and end up in intensive care. Overall, they have worse quality of life and more distress.”
This information prompted ASCO and the National Quality Forum (NQF) to endorse NQF 0210, which measures the number of patients who died of cancer after receiving chemotherapy in the last 14 days of their lives.
NQF 0210 “has been widely adopted, used in cancer quality reporting and value-based care programs, and has recently been expanded to include all types of systemic therapy, including targeted therapies, immunotherapies and oral therapies,” researchers wrote.
However, effort has not changed the national mean proportion of anticancer therapies given within 14 days of death (17% in both 2015 and 2019).
Criticisms of NQF 0210 include looking back following death, which could misclassify individuals who had low mortality risk but died due to other complications. It also does not account for those who improved with treatment.
Researchers stratified practices based on NQF 0210 rates to help bridge that knowledge gap.
“We thought it was important to study whether there is evidence to support oncologists’ belief that systemic treatment for advanced solid tumors has clinical survival benefit,” Adelson said.
Methodology
Investigators used the Flatiron Health electronic health-record derived database, used by roughly 280 cancer clinics (800 sites) in the U.S., to build their study cohort.
They included individuals aged 18 years and older diagnosed with stage IV breast, colorectal or pancreatic cancer, or renal cell carcinoma, stage IIIB/stage IIIC or stage IV NSCLC or nodal positive or stage IV urothelial cancer between 2015 and 2019. They excluded patients with multiple cancer diagnoses.
The investigation separated practices into quintiles based on NQF 0210 rates and compared OS among patients with matching cancer types.
“If a significant proportion of patients benefit from treatment at the point of very advanced disease, practices with higher rates on the NQF 0210 metric would be expected to have improved survival when all patients (not just decedents) are followed prospectively,” researchers wrote. “Moreover, patients receiving care at practices with lower rates on the NQF 0210 metric would have shorter OS because they may be denied potentially beneficial anticancer treatments.”
The study cohort consisted of 78,446 adults (67.5% white), including a majority of women (52.2%) and more than one-third (37.2%) aged older than 65 years. The most frequent cancer types included 43.6% with NSCLC and 20.1% with colorectal cancer.
Adults in the highest quintile practices tended to be older, categorized as “other” or “unknown” race and had commercial health plans.
Results and next steps
Researchers did not find significant survival differences between quintiles.
Patients with renal cell carcinoma in the top quintile had superior OS (HR = 0.77; 95% CI, 0.55-0.99) to those in the bottom quintile, but after statistical adjustments, researchers deemed the result not statistically significant.
Hazard ratios for other cancer types did not produce significant differences.
“There were some differences in OS based on 30-day end-of-life treatment quintiles across cancer types; however, none of these survival differences were statistically significant,” researchers wrote.
The results support more palliative care at end of life, Adelson said.
“Earlier referral to palliative care has been shown to improve quality of life, and in some studies, even survival,” he explained. “Instead of offering continuation of systemic cancer-directed therapy for patients nearing the end of life, doctors should communicate openly and honestly about prognosis, and help patients transition from cancer-directed therapy to palliative care and hospice.”
Researchers believe end-of-life treatments continue to be administered at consistent rates due to several factors, including some clinicians not wanting to take away hope from patients or believing additional treatments could produce improved OS. Economics of administration and access to hospice care are factors too.
“There is a desperate need to develop interventions that enable oncologists to provide better end-of-life care,” Adelson said. “In particular, there is a need for risk stratification tools that will help oncologists identify when the end of life is approaching and further therapy is likely to be futile. There is a need to develop models to scale communication training to improve oncologist communication skills and comfort level in telling patients that further treatment does not have benefit. There is a need to look at whether continuation of contemporary cancer drugs, including targeted and immunotherapies, is associated with worse outcomes.”
Study limitations included lack of information on treatment preferences for clinicians and patients as well as hospice referrals. Additionally, some clinicians could be more skilled at predicting when a patient may die, which could also lead to better decision making.
Adelson believes rewarding different approaches toward end-of-life care could greatly benefit patients.
“Policymakers could explore incentive-based approaches to improve end-of-life care, such as reducing reimbursement for use of high-cost drugs in nonbeneficial settings and increasing reimbursement for earlier goals of care conversations, palliative care referrals, and incentivizing and enforcing provision of comprehensive hospice services,” Adelson said.
For more information:
Kerin B. Adelson, MD, can be reached at kbadelson@mdanderson.org.
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