End-of-Life Care for Patients With Metastatic Renal Cell Carcinoma in the Era of Oral Anticancer Therapy

Abstract

PURPOSE: New therapies including oral anticancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC). However, little is known about the quality of end-of-life (EOL) care and systemic therapy use at EOL in patients receiving OAAs or with mRCC. METHODS: We retrospectively analyzed EOL care for decedents with mRCC in two parallel cohorts: (1) patients (RCC diagnosed 2004-2015) from the University of North Carolina's Cancer Information and Population Health Resource (CIPHR) and (2) patients (diagnosed 2007-2015) from SEER-Medicare. We assessed hospice use in the last 30 days of life and existing measures of poor-quality EOL care: systemic therapy, hospital admission, intensive care unit admission, and > 1 ED visit in the last 30 days of life; hospice initiation in the last 3 days of life; and in-hospital death. Associations between OAA use, patient and provider characteristics, and EOL care were examined using multivariable logistic regression. RESULTS: We identified 410 decedents in the CIPHR cohort (53.4% received OAA) and 1,508 in SEER-Medicare (43.5% received OAA). Prior OAA use was associated with increased systemic therapy in the last 30 days of life in both cohorts (CIPHR: 26.5% v 11.0%; P < .001; SEER-Medicare: 23.4% v 11.7%; P < .001), increased in-hospital death in CIPHR, and increased hospice in the last 30 days in SEER-Medicare. Older patients were less likely to receive systemic therapy or be admitted in the last 30 days or die in hospital. CONCLUSION: Patients with mRCC who received OAAs and younger patients experienced more aggressive EOL care, suggesting opportunities to optimize high-quality EOL care in these groups.

End-of-Life Care Among Patients With Metastatic Renal Cell Carcinoma: Importance of a Patient-Centric Focus in Clinical Decision Making

“…11,12 To better understand this phenomenon in the context of renal cell carcinoma (RCC), a recent study published in JCO Oncology Practice employed a retrospective analysis using the University of North Carolina Cancer Information Population Health Resource (CIPHR) and the SEER Medicare database to determine EOL care and systemic therapy use among patients with metastatic RCC receiving OAA. 13 Dzimitrowicz et al noted that almost half the nearly 2,000 patients assessed received an OAA in the period between metastatic diagnosis and 30 days before death. From the sample of patients who did not receive OAA, it appears that 16% of patients had received systemic therapies, including targeted therapy/immunotherapy (8%) and cytotoxic (7%) and cytokine therapies (1%).…”

“…Within the SEER database, patients enrolled in Medicare and Medicaid were found to have a higher likelihood of in-hospital death and lower likelihood of any hospice use in the last 30 days. 13 Patients from non-White race, male sex, those living in rural locations, the northeast region, or with metastatic disease were classified as being more likely to receive low-quality EOL care, on the basis of elements including ICU admission and systemic therapy in the last month of life. 13…”

“…13 Patients from non-White race, male sex, those living in rural locations, the northeast region, or with metastatic disease were classified as being more likely to receive low-quality EOL care, on the basis of elements including ICU admission and systemic therapy in the last month of life. 13…”

“…Within the SEER database, patients enrolled in Medicare and Medicaid were found to have a higher likelihood of in-hospital death and lower likelihood of any hospice use in the last 30 days. 13 Patients from non-White race, male sex, those living in rural locations, the northeast region, or with metastatic disease were classified as being more likely to receive low-quality EOL care, on the basis of elements including ICU admission and systemic therapy in the last month of life. 13 Although this study provides important insight into the EOL care among patients with metastatic renal cell carcinoma, 13 the time period during which the data were retrospectively collected should be noted (CIPHR 2004-2015and SEER 2007-2015.…”

“…13 Patients from non-White race, male sex, those living in rural locations, the northeast region, or with metastatic disease were classified as being more likely to receive low-quality EOL care, on the basis of elements including ICU admission and systemic therapy in the last month of life. 13 Although this study provides important insight into the EOL care among patients with metastatic renal cell carcinoma, 13 the time period during which the data were retrospectively collected should be noted (CIPHR 2004-2015and SEER 2007-2015. Indeed, despite discussion of EOL measures since the early 2000s, it was only in 2012 that a provisional clinical measure was introduced.…”