Background: Immunotherapy is a relatively new, promising cancer therapy with a lower toxicity profile compared to chemotherapy. Is end of life initiation immunotherapy (EOL-I Immunotherapy) being used more commonly?
Design and Participants: Using the National Cancer Database (NCDB), a retrospective cohort study gathered information on those diagnosed with stage IV metastatic melanoma, non-small cell lung cancer (NSCLC), or kidney cell carcinoma (KCC) after December 2019 when immunotherapy was FDA approved. Data analysis was performed between December 2022 and May 2023. The primary outcome was immunotherapy initiation within the last month of life. Immunotherapy status (none, immunotherapy initiated more than a month before death, and immunotherapy initiated within one month of death) was reported by cancer type. P < .05 was considered significant. χ2 tests and 1-way analysis of variance assessed differences between groups. Facility type, academic or nonacademic, and hospital volume were independent variables of interest. Hospital volume was determined separately for each of the 3 cancers and defined as number of patients with metastatic disease treated at the facility over the timeframe of the study.
Results: 242,371 patients were analyzed. 71,204 of those received immunotherapy, and, of those, 5192 received immunotherapy within the last month of life. This represents 3% of those with melanoma, 3% of those with non-small cell lung cancer, and 2% of those with kidney cell carcinoma. Treatment at an academic or high-volume institution was associated with significant decrease in odds of EOL-I Immunotherapy for all cancer types, (odds ratio [OR], 0.69; 95% CI, 0.65-0.74; P < .001) and 30% (OR, 0.70; 95% CI, 0.65-0.76; P < .001). The factor associated with greater odds of EOL-I Immunotherapy was metastases in at least 3 solid organs.
Commentary: The rate of use of immunotherapy within one month of death for those with metastatic melanoma, NSCLC, and KCC is increasing significantly; this is in association with the general increased use of immunotherapy. Immunotherapy near the end of life can be with negative outcomes like increased hospitalization and emergency department visits, increased risk of hospital death, delayed palliative care referral, increased patient cost, and poor performance status. Some differences are noted between EOL-I Immunotherapy at different facility types where there are lower odds of EOL-I immunotherapy at high volume, academic centers compared to low volume, nonacademic centers. One hypothesis is that a high-volume center may have more experience with adverse effects of immunotherapy, so may prescribe immunotherapy more cautiously.
Bottom Line: Tracking the trend of EOL-I Immunotherapy highlights changes in clinical approach to those with metastatic cancer. There is a need to develop better predictors of nonresponse to immunotherapy.
Source: Kerekes DM, Frey AE, Prsic EH, et al. Immunotherapy Initiation at the End of Life in Patients With Metastatic Cancer in the US. JAMA Oncol. 2024;10(3):342–351. doi:10.1001/jamaoncol.2023.6025.
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