Immune checkpoint inhibitor use near the end of life.

Abstract

11533 Background: Studies of chemotherapy near the end of life reveal increased costs, adverse effects and minimal clinical benefit. Immune Checkpoint Inhibitor (ICI) use near the end of life has not been described. We studied factors related to ICI use near the end of life. Methods: We conducted a single-institution retrospective chart review of patients who received ICI and died between August 2014 and December 2018. End of life ICI (EOL-ICI) was defined as treatment within the last 30 days of life and comparisons were made to patients who received treatment > 30 days from end of life (non EOL-ICI). Results: 441 patients were reviewed. Mean age was 64 and 182 (41%) were female. 294 (67%) received ICI within the last 90 days of life and 117 (27%) within the last 30 days of life. At time of last ICI, 145 (33%) had brain metastases and 416 (94%) were stage 4. The most common cancers were melanoma (124, 28%), NSCLC (118, 27%) and urothelial carcinoma (34, 8%). The EOL-ICI group had a higher proportion of patients with ECOG ≥3 at time of last treatment (22% vs. 7%, p = < .001), higher rate of death in hospital (32% vs. 18%, p = 0.003) and lower hospice enrollment (52% vs. 76%, p = < .001). The EOL-ICI group received fewer ICI doses (mean 5.1 vs 6.7, p = 0.016). A higher proportion of patients in the EOL-ICI group were just beginning treatment and received ≤ 3 doses (60% vs 40%, p < .001). There was no difference in mean age or presence of brain metastases between the groups. Even when the cutoff for EOL-ICI is extended from 30 to 90 days, there remain significant differences in ECOG, hospice enrollment and starting ICI but no difference in rate of dying in the hospital. Conclusions: One out of four patients studied received ICI within the last 30 days of life. EOL-ICI treatment is associated with higher rates of death in the hospital and lower hospice enrollment. Our results suggest that performance status is important when considering treatment with ICI. Use of ICI in the last 30 days of life had minimal clinical benefit and high cost.

Clinical Outcomes of Patients with Metastatic Cancer Receiving Immune Checkpoint Inhibitors in the Inpatient Setting

“…The value of performance status in predicting mortality following ICI administration is supported by data from clinical trials of pembrolizumab, which show shorter OS in patients with NSCLC who have PS 2 rather than PS 0-1 [12,13]. Real-world analysis of patients who received ICI therapy close to end of life has also identified PS 3-4 as a poor prognostic factor [14,15]. Nevertheless, Journal of the National Comprehensive Cancer Network guidelines currently recommend singleagent pembrolizumab as first-line therapy in patients with NSCLC who cannot tolerate platinum-based chemotherapy [16].…”

Effects of molecular targeting agents and immune-checkpoint inhibitors in patients with advanced cancer who are near the end of life

“…The ICI use near EOL is associated with a poor performance status, lower hospice enrollment, and death in the hospital (Glisch et al, 2020). As the ICI use near EOL was a significant predictor in our study, attention should be paid to the prolonged use of ICIs for patients with poor Performance Status for the same reasons as for the MTAs.…”

“…Recently, the use of both MTAs and ICIs has occupied important positions in SACT. However, there are few reports on the effects of using MTAs and ICIs near EOL in patients with advanced cancer in SACT (Hui et al, 2013; Tsai et al, 2018; Glisch et al, 2020), while other reports focused only on CTAs (Earle et al, 2004; Barbera et al, 2006; Braga et al, 2007; Hashimoto et al, 2009; Kao et al, 2009; Näppä et al, 2011; Hanny et al, 2014; Petra et al, 2015; Maltoni et al, 2016; Hikmat et al, 2019; Hiramoto et al, 2019; Glisch et al, 2020).…”