Study shows that immunotherapy initiation at the end of life has increased over time


In US, the trend was more frequently seen at very low-volume and nonacademic centers than at high-volume and academic centers

Despite the use of immune checkpoint inhibitors at the end of life (EOL) is associated with a higher risk of dying in hospital (Am J Hosp Palliat Care. 2020 Mar;37(3):179-184), a study reports that immunotherapy initiation has become more common for the management of patients with metastatic melanoma, non-small cell lung cancer (NSCLC) and kidney cell carcinoma (KCC) in the last month of life.

A research team from the Yale School of Medicine, New Haven, US, analysed data for 242,371 patients from the National Cancer Database, a clinical oncology database that reports demographic variables, treatment details, and outcomes for all patients with a cancer diagnosis treated at an American College of Surgeons Commission on Cancer–accredited facility. For the three cancer types which were chosen for the study group, three different time periods were set, each starting the year immediately following US Food and Drug Administration approval of the first immune checkpoint inhibitor for the treatment of stage IV disease for that tumour (2012 for melanoma, 2016 for NSCLC and KCC). The end of each study period was 2019 for all cancers.

Overall, a significant increase of the percentage of patients with metastatic disease who started immunotherapy within one month of death was observed in the study (from 0.8% to 4.3% for melanoma, from 0.9% to 3.2% for NSCLC, and 0.5% to 2.6% for KCC). The trend is aligned with a growing use of immune checkpoint inhibitors at any stage of cancer trajectory over more than a decade. When analysing datasets by facility type and hospital volume, it emerged that EOL immunotherapy was more commonly administered at very low-volume and nonacademic centers than at high-volume and academic centers. Also, patients receiving active treatment in the last weeks of their lives were those with the highest metastatic burden.

EOL care is a very personal choice that relies on detailed discussions and shared decision making between the patients, their families and healthcare providers. However, active anticancer therapy is often discouraged at the EOL due to an imbalance between low expected benefits and potential toxicity. The ESMO Clinical Practice Guidelines for the care of the adult cancer patient at the end of life recommend that chemotherapy and immunotherapy should not be used in the last weeks of life, and radiotherapy should not be used in the last days of life (ESMO Open. 2021;6:100225).

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