Novel Systemic Anticancer Treatments and Health Services Use the End of Life Among Adults With Cancer

Author(s): Javaid Iqbal, MD, MSc^1,2; Rahim Moineddin, PhD^3,4; Kieran L. Quinn, MD, PhD^4,5,6,7; Christopher M. Booth, MD⁸; Craig C. Earle, MD, MSc^6,9; Stephanie Lheureux, MD, PhD^2,6,7,10; Robert Grant, MD, PhD^2,6,7,10; Jenny Lau, MD, MSc^1,2; Lisa W. Le, MSc¹¹; Peter Tanuseputro, MD, MHSc¹²; James Downar, MD, MHSc^13,14; Gary Rodin, MD^1,2,4,6,15; Hsien Seow, PhD¹⁶; Jillian Tsai, MD, PhD¹⁷; Robert A. Fowler, MDCM, MS^4,5,6,18; Breffni Hannon, MBBCh, MMedSci^1,2,6,7; Monika K. Krzyzanowska, MD, MPH^2,4,5,6,9; Camilla Zimmermann, MD, PhD, MPH^1,2,4,5,6,7;

Source: DOI: 10.1200/JCO-24-02816

Dr. Maen Hussein's Thoughts

This study reviewed the effects of using novel agents (immunotherapy and targeted therapy) in patients at the end of life (EOL), based on the perception that these therapies may be less toxic than chemotherapy. Adjusted odds of high health service utilization and hospital death were more than twofold greater among patients receiving systemic anticancer therapy (SACT) at the EOL compared to those receiving none.

PURPOSE

Use of chemotherapy the end of life (EOL) is discouraged, but evidence to guide decisions on the use of novel systemic anticancer treatment (SACT) agents is lacking. We examined trends of use among SACT types and association with health services use the EOL.

MATERIALS AND METHODS

We analyzed Canadian Ontario Cancer Registry data for adults diagnosed with solid tumors or hematologic malignancies within 5 years of death who received SACT between March 2015 and March 2021. Receipt of SACT in the last 30 days of life was categorized as chemotherapy alone, chemotherapy and immunotherapy, immunotherapy alone, and targeted therapy alone. Outcomes included high health services use, including multiple (≥2) emergency department (ED) visits, multiple (≥2) hospitalizations, or any (≥1) intensive care unit admission, and hospital deaths. Segmented linear regression estimated monthly trends; multivariable logistic regression estimated adjusted odds ratios (aORs) of outcomes for various SACT types.

RESULTS

Among 68,963 patients, 18,337 (26.6%) received SACT the EOL. From March 2015 to March 2020, use of SACT the EOL increased (0.072% per month; P < .001), mainly driven by increased use of immunotherapy alone (0.064% per month; P < .001). Adjusted odds of high health services use and hospital death were more than two-fold greater among patients receiving SACT the EOL (vs. none); individual aORs of high health services use and hospital death were 2.20 and 2.72 for chemotherapy alone, 2.36 and 3.10 for chemotherapy and immunotherapy, 1.92 and 2.27 for immunotherapy alone, and 1.75 and 2.37 for targeted therapy alone, respectively.

CONCLUSION

Use of SACT the EOL increased significantly over time, driven by increased use of immunotherapy. SACT use the EOL, regardless of its type, was associated with high health services use and hospital death. Guidelines on the use of SACT the EOL should include novel cancer treatments.

Author Affiliations

¹Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada; ²Institute of Medical Science, University of Toronto, Toronto, ON, Canada; ³Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; ⁴Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; ⁵Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ⁶Department of Medicine, University of Toronto, Toronto, ON, Canada; ⁷Department of Medicine, University Health Network and Sinai Health, Toronto, ON, Canada; ⁸Department of Oncology, Queen's University, Kingston, ON, Canada; ⁹Medical Oncology & Malignant Hematology Division, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ¹⁰Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada; ¹¹Department of Biostatistics, University of Health Network, Toronto, ON, Canada; ¹²Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China; ¹³Department of Medicine, University of Ottawa, Ottawa, ON, Canada; ¹⁴Bruyere Research Institute, Bruyere Continuing Care, Ottawa, ON, Canada; ¹⁵Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; ¹⁶Department of Oncology, McMaster University, Hamilton, ON, Canada; ¹⁷Department of Radiation Oncology, University of Toronto, and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; ¹⁸Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada

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