Difficult decisions: Slow changes for overuse of therapy at end of life
For the past few years, one component of my role as a member of the physician leadership team for oncology has been to authorize some types of inpatient treatments, especially those not typically reimbursed by insurance carriers.
These approvals fall into two major categories. In recent years, one of these has been for the use of anti-tumor necrosis factor antibodies for patients experiencing toxicity from checkpoint inhibitors, who are hospitalized in view of the severity of their symptoms.
The second common situation is the use of antineoplastic agents for patients with advanced/metastatic disease, usually in a second-line or later setting, where the oncologist and patient and/or caregivers have reached an agreement that they wish to go ahead with further therapy.
Of course, there are many clinical settings in which this is highly appropriate — hematologic malignancies or other tumors with well-established and highly effective second- and third-line therapies are good examples.
That said, it is now very well-established that the use of antineoplastic therapy for some patients with limited life expectancy is associated with poor quality of life, inappropriate use of acute hospital and intensive care beds, high costs and, in some cases, even reduced OS.
As awareness of the poor outcomes associated with so-called “end-of-life” therapy for cancer increases, I feel increasingly conflicted each time I have to authorize this kind of treatment.
On the one hand, as someone who tries hard to be data-driven, I am aware of the preponderance of evidence that shows very poor outcomes in this patient group — a recent analysis from my previous center showed a median OS of less than 4 months for patients admitted to the inpatient service with advanced solid tumors who received any form of systemic antineoplastic therapy in the second-line or later setting.
On the other hand, I assume, appropriately, that my colleagues are acting in the best interests of the patient, and that after discussing goals of care and likely prognosis have come to a joint decision to go ahead with further therapy. Because I am not directly involved in the care of the patient, I will always respect the wishes of the care team and the patient.
The apparent overuse of systemic or other cancer therapies in apparently futile settings has attracted much attention and has been widely covered in peer-reviewed literature, as well as in publications such as HemOnc Today.
Many centers are developing strategies to address the overuse of cancer therapies for hospitalized patients with very limited prognosis. These strategies have included algorithms and pathways that require palliative care consults, best practice alerts that direct the provider to a goals-of-care discussion, mechanisms for early discharge to home or to hospice, and many other interventions.
The success of these approaches is not clear, although there are some early indicators that the use of systemic cancer therapy, especially chemotherapy, within 30 days of the end of life may be declining for patients with advanced solid tumors. It’s possible that the attention that has been paid to this issue in recent years and the realization that it represents a major opportunity to improve quality and value of care has been recognized, and that practice is slowly changing.
Newly diagnosed patients
A less common, but no less difficult, situation arises when a patient with a new diagnosis of an advanced solid tumor presents for possible treatment.
There are relatively little data about the use of therapy in this group, and a recent study, based on the National Cancer Database (NCDB), provides some interesting insights into this challenging situation.
Sineshaw and colleagues identified more than 100,000 patients with newly diagnosed advanced solid tumors — including lung, colorectal, breast and pancreatic cancer — who were diagnosed between 2004 and 2014 and who died within a month of initial diagnosis. They investigated the impact of several patient-related, disease-related and socioeconomic/demographic factors on treatment patterns.
Perhaps the most encouraging observation from the study, in common with other recent reports, is a reduction in the use of all cancer treatment modalities over the study period in these patient groups. Interestingly, this decline was particularly true for the use of surgery to the primary tumor and is consistent with NCCN guidelines.
Although that observation suggests progress, there are many findings from the study that merit further discussion.
Firstly, and not surprisingly, patients aged 75 years and older were less likely to receive radiation or chemotherapy for lung cancer or chemotherapy for breast cancer than younger patients. These data also demonstrate a relationship between comorbidity score and receipt of therapy, showing, in a predictable trend, that comorbidity predicted for a lower likelihood of therapy, at least for some tumors, including pancreatic and lung cancer.
There were some concerning differences in care related to insurance status, with lower use of chemotherapy among uninsured patients than those who were privately insured. Whether this apparent disparity resulted in poorer outcomes is unclear.
The study also showed marked variations in care according to whether patients were treated at academic (mostly NCI-designated) cancer centers compared with community-based settings. There was no clear overall pattern to this variation — in some situations, for example, surgical intervention was more common at academic centers, whereas in others, this trend was reversed — but some of the differences were more than twofold. It’s not clear what is driving these differences.
As the researchers acknowledge, the conclusions of the study are limited by its retrospective nature and the lack of granularity associated with NCDB data, but it does provide further insight into our management of patients with advanced cancer and suggests some areas for further investigation.
Although I think many of us consider previously untreated patients with advanced cancer to be somehow different from those who have received several lines of therapy, that is probably not the case for most, particularly those who are older and who have significant comorbidities. Data from my previous center shows that previously untreated patients admitted to our hospital with a new diagnosis of advanced cancer had a median OS of just over 6 months.
These data add to the burgeoning literature on the apparent overuse of cancer therapy for patients who are very unlikely to benefit. They suggest that there has been a small decline in the use of treatment close to the end of life in this group, representing the same trend as in those with prior treatment.
The key to maintaining this trend will be to ensure that we as providers improve our ability to engage in meaningful goals-of-care discussions with realistic evaluations of the likelihood of response and survival, allowing our patients and their caregivers to make well-informed, although extremely difficult, decisions.
Kraut J, et el. J Oncol Pract. 2019;doi:10.1200/JOP.18.00408.
Sineshaw HM, et al. JNCI Cancer Spectr. 2019;doi:10.1093/jncics/pkz021.
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John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at email@example.com.
Disclosure: Sweetenham reports no relevant financial disclosures.