End of Life Immunotherapy Use Is Increasing in Metastatic Cancer

“As global experience with immunotherapy continues to grow, clinicians are learning where to draw the line for patient selection such that delivery of nonbeneficial treatment is minimized and patient outcomes are optimized. Prospective data on predictors of nonresponse to immunotherapy, including biomarkers and genetic testing, will be essential to guiding this process," according to the study authors.

After findings from a cohort study indicated that initiation of end of life (EOL) immunotherapy is increasing in cancer care, investigators reported that tracking usage may yield insights into national prescribing patterns and lead to changes in how advanced disease is managed.

Investigators reported that EOL immunotherapy use increased in patients across all cancer types. More than 1 in 14 instances of immunotherapy treatment in 2019 began within 1 month of death. Those who were risk-adjusted with 3 or more organs involved with metastatic disease were 3.8-fold (95% CI, 3.1-4.7; P <.001) more likely to die within a month of beginning immunotherapy compared with those who had lymph node involvement only. Additionally, receipt of treatment at an academic or high-volume center vs a nonacademic or very low–volume facility was associated with a 31% (OR, 0.69; 95% CI, 0.65-0.74; P <.001) and 30% (OR, 0.70; 95% CI, 0.65-0.76; P <.001) lower risk of death within a month of beginning an immunotherapeutic.

“As global experience with immunotherapy continues to grow, clinicians are learning where to draw the line for patient selection such that delivery of nonbeneficial treatment is minimized and patient outcomes are optimized,” the authors wrote. “Prospective data on predictors of nonresponse to immunotherapy, including biomarkers and genetic testing, will be essential to guiding this process.”

The study authors utilized the National Cancer Database, which includes demographic variables, treatment details, and patient outcomes. Investigators incorporated several disease types that were found to have the highest volume and longest longitudinal experience with immunotherapy, including stage IV melanoma, non–small cell lung cancer (NSCLC), and kidney cell carcinoma (KCC). The study included patients who were 18 years or older who had been diagnosed with stage IV cancer. Those with unknown immunotherapy status or unknown timing of immunotherapy were not eligible to be included.

A total of 242,371 patients were included in the analysis. It was reported that the mean age was 67.9 years, with 42.5% of patients being more than 70 years of age. Additionally, 56.0% of patients were men, and 29.3% underwent treatment with immunotherapy.

Moreover, 57% of patients did not receive immunotherapy, 41% were treated with immunotherapy and lived for more than 1 month after beginning treatment, and 3% were treated with EOL immunotherapy. In the melanoma cohort (n = 20,415), 57%, 41%, and 3% of patients did not receive immunotherapy, received immunotherapy and lived longer than 1 month, and received EOL immunotherapy, respectively; investigators also reported immunotherapy status in the NSCLC (n = 197,331; 72%, 26%, and 3%) and KCC cohorts (n = 24,625; 73%, 26%, and 2%), respectively.

Investigators reported that both academic and high-volume facilities prescribed the most immunotherapy across all disease types. Additionally, receipt of EOL immunotherapy was found to increase parallel to the increase in overall immunotherapy rate; this included an increase from 0.8% to 4.3% in the melanoma cohort, 0.9% to 3.2% for NSCLC, and 0.5% to 2.6% for KCC. Moreover, EOL chemotherapy decreased in the melanoma group from 8.8% in 2012 to 5.1% in 2019 (P = .04); conversely, there was no significant change in proportion of EOL immunotherapy treatment (5.0% to 6.9%; P = .20).

Reference

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. Published online January 4, 2024. doi:10.1001/jamaoncol.2023.6025