Trends in end-of- life (EOL) systemic oncologic treatment in contemporary clinical practice: Insights from real-world data.

Authors

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Maureen Canavan

Yale School of Medicine, New Haven, CT

Maureen Canavan, Xiaoliang Wang, Mustafa Ascha, Rebecca A. Miksad, Timothy N Showalter, Gregory Sampang Calip, Cary Philip Gross, Kerin B. Adelson

Organizations

Yale School of Medicine, New Haven, CT, Flatiron Health, New York, NY, Case Western Reserve University School of Medicine, Cleveland, OH, University of Virginia, Charlottesville, VA, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, Yale Cancer Center, Smilow Cancer Hospital at Yale New Haven Health, New Haven, CT

Research Funding

No funding received
None

Background: Among patients with cancer, receipt of systemic oncolytic therapy near the end-of-life (EOL) does not improve outcomes and worsens patient and caregiver experience. Accordingly, the ASCO/NQF measure, Proportion Receiving Chemotherapy in the Last 14 Days of Life, was published in 2012. Over the last decade there has been exponential growth in high cost targeted and immune therapies which may be perceived as less toxic than traditional chemotherapy. In this study, we identified rates and types of EOL systemic therapy in today’s real-world practice; these can serve as benchmarks for cancer care organizations to drive improvement efforts. Methods: Using data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we included patients who died during 2015 through 2019, were diagnosed after 2011, and who had documented cancer treatment. We identified the use of aggressive EOL systemic treatment (including, chemotherapy, immunotherapy, and combinations thereof) at both 30 days and 14 days prior to death. We estimated standardized EOL rates using mixed-level logistic regression models adjusting for patient and practice-level factors. Year-specific adjusted rates were estimated in annualized stratified analysis. Results: We included 57,127 patients, 38% of whom had documentation of having received any type of systemic cancer treatment within 30 days of death (SD: 5%; range: 25% - 56%), and 17% within 14 days of death (SD: 3%; range: 10% - 30%). Chemotherapy alone was the most common EOL treatment received (18% at 30 days, 8% at 14 days), followed by immunotherapy (± other treatment) (11% at 30 days, 4% at 14 days). Overall rates of EOL treatment did not change over the study period: treatment within 30 days (39% in 2015 to 37% in 2019) and within 14 days (17% in 2015 to 17% in 2019) of death. However, the rates of chemotherapy alone within 30 days of death decreased from 24% to 14%, and within 14 days, from 10% to 6% during the study period. In comparison, rates for immunotherapy with chemotherapy (0%-6% for 30 days, 0% -2% for 14 days), and immunotherapy alone or with other treatment types (4%-13% for 30 days, 1%-4% for 14 days) increased over time for both 30 and 14 days. Conclusions: End of life systemic cancer treatment rates have not substantively changed over time despite national efforts and expert guidance. While rates of traditional chemotherapy have decreased, rates of costly immunotherapy and targeted therapy have increased, which has been associated with higher total cost of care and overall healthcare utilization. Future work should examine the drivers of end-of-life care in the era of immune-oncology.

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Abstract Details

Meeting

2021 ASCO Quality Care Symposium

Session Type

Poster Session

Session Title

Poster Session B: Patient Experience; Quality, Safety, and Implementation Science; Technology and Innovation in Quality of Care

Track

Technology and Innovation in Quality of Care,Patient Experience,Quality, Safety, and Implementation Science,Cost, Value, and Policy,Health Care Access, Equity, and Disparities

Sub Track

Quality Improvement Research and Implementation Science

Citation

J Clin Oncol 39, 2021 (suppl 28; abstr 253)

DOI

10.1200/JCO.2020.39.28_suppl.253

Abstract #

253

Poster Bd #

D6

Abstract Disclosures