Utilization of systemic therapy in cancer patients near the end-of-life in the pre- vs. post-checkpoint inhibitor eras

Introduction: Use of systemic therapy for advanced cancer patients near the end-of-life (EOL) is a low-value medical practice. However, immune checkpoint inhibitor (ICI) use at the EOL may be on the rise due to a favorable toxicity profile. We hypothesize that systemic therapy use in the last 30 days of life (DOL) increased since ICI approval in 2014.
Methods: We investigated the change in prevalence of systemic therapy use in the last 30 DOL before and after the first anti-PD-1 ICI was approved in September 2014. We used cases from Fred Hutchinson Cancer Research Center’s population-based Cancer Surveillance System linked to commercial and Medicare insurance claims. Patients who died between 2011-2018, with AJCC stage 3, 4 or unknown solid tumors and six months of continuous insurance coverage were included. Secondary analyses measured cost of care during the last 30 DOL.
Results: A total of 8,871 patients (median age 73) were included in the analysis with 34% in the pre-ICI period (2011-2014) and 66% in the post-ICI period (2014-2018). Prevalence of systemic therapy in the last 30 DOL was lower in the post-ICI period vs pre-ICI period (12.4% vs 14.4%; difference -2.0% [95% CI -3.5 to -0.5]). The annual prevalence of systemic therapy in the last 30 DOL also declined, though ICI use comprised a rising proportion of systemic therapy. Relative to those receiving non-ICI systemic therapy, patients treated with ICI in last 30 DOL had higher overall costs and drug costs.
Discussion: Systemic therapy use in the last 30 DOL was lower in the period after ICI approval. However, ICI use rose during the study period and had higher costs than those receiving non-ICI systemic therapy in last 30 DOL. Systemic therapy use at the EOL warrants close monitoring, especially as ICI availability may enable treatment in older, frailer patients approaching the EOL.