Adoption of Immune Checkpoint Inhibitors and Patterns of Care at the End of Life

Abstract

PURPOSE: As immune checkpoint inhibitors (ICIs) have transformed the care of patients with cancer, it is unclear whether treatment at the end of life (EOL) has changed. Because aggressive therapy at the EOL is associated with increased costs and patient distress, we explored the association between the Food and Drug Administration (FDA) approvals of ICIs and treatment patterns at the EOL. METHODS: We conducted a retrospective, observational study using patient-level data from a nationwide electronic health record–derived database. Patients had advanced melanoma, non–small-cell lung cancer (NSCLC; cancer types with an ICI indication), or microsatellite stable (MSS) colon cancer (a cancer type without an ICI indication) and died between 2013 and 2017. We calculated annual proportions of decedents who received systemic cancer therapy in the final 30 days of life, using logistic regression to model the association between the post-ICI FDA approval time and use of systemic therapy at the EOL, adjusting for patient characteristics. We assessed the use of chemotherapy or targeted/biologic therapies at the EOL, before and after FDA approval of ICIs using Pearson chi-square test. RESULTS: There was an increase in use of EOL systemic cancer therapy in the post-ICI approval period for both melanoma (33.9% to 43.2%; P < .001) and NSCLC (37.4% to 40.3%; P < .001), with no significant change in use of systemic therapy in MSS colon cancer. After FDA approval of ICIs, patients with NSCLC and melanoma had a decrease in the use of chemotherapy, with a concomitant increase in use of ICIs at the EOL. CONCLUSION: The adoption of ICIs was associated with a substantive increase in the use of systemic therapy at the EOL in melanoma and a smaller yet significant increase in NSCLC.

Is there an overtreatment of melanoma patients at the end of their life? Results of a multicenter study on 193 melanoma patients

“…Especially immune checkpoint inhibitors (ICI) with PD‐1‐ and/or CTLA‐4 blockade and targeted therapies (TT) with BRAF and MEK inhibitors have significantly improved the prognosis of metastatic melanoma patients. These treatments are therefore widely used, even for patients who may have a reduced chance of treatment response and/or an increased risk of side effects, such as patients with poor baseline performance status, multiple pretreatments or multiple comorbidities [8–13].…”

Gibt es eine Überbehandlung von Melanompatienten am Ende ihres Lebens? Ergebnisse einer multizentrischen Studie an 193 Melanompatienten

“…Insbesondere Immuncheckpoint‐Inhibitoren (ICI) mit PD‐1‐ und/oder CTLA‐4‐Blockade und zielgerichtete Therapien (targeted therapy; TT) wie BRAF‐ und MEK‐Inhibitoren haben die Prognose von Patienten mit metastasiertem Melanom deutlich verbessert. Diese Behandlungen werden daher in großem Umfang eingesetzt, mitunter auch bei Patienten, die nur eine geringere Chance auf ein Ansprechen auf die Behandlung und/oder ein erhöhtes Risiko für Nebenwirkungen haben, wie zum Beispiel Patienten mit reduziertem Allgemeinzustand, multiplen Vortherapien oder Komorbiditäten [8–13].…”

Systemic melanoma therapy at the end of life: A single institutional retrospective study in Japan

“…However, some caveats remain concerning the excessive drug use in terminal-stage melanoma due to high expectations for their efficacy and tolerability. 1 , 2 , 3 , 4 , 5 The present study compared the use of anticancer agents in terminal-stage melanoma before and after the introduction of novel agents and identified factors associated with making decisions at the end of life (EOL), especially focused on the final 30 days of life. 1 , 2 , 3 , 4 …”

“… 1 , 2 , 3 , 4 , 5 The present study compared the use of anticancer agents in terminal-stage melanoma before and after the introduction of novel agents and identified factors associated with making decisions at the end of life (EOL), especially focused on the final 30 days of life. 1 , 2 , 3 , 4 …”