End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting

Abstract

PURPOSE Receipt of antineoplastic systemic treatment near end of life (EOL) has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit and emergency department use, and drive-up costs; yet, these rates have not declined. To understand factors contributing to use of antineoplastic EOL systemic treatment, we explored its association with practice- and patient-level factors. METHODS We included patients from a real-world electronic health record–derived deidentified database who received systemic therapy for advanced or metastatic cancer diagnosed starting in 2011 and died within 4 years between 2015 and 2019. We assessed use of EOL systemic treatment at 30 and 14 days before death. We divided treatments into three subcategories: chemotherapy alone, chemotherapy and immunotherapy in combination, and immunotherapy (with/without targeted therapy), and estimated conditional odds ratios (ORs) and 95% CIs for patient and practice factors using multivariable mixed-level logistic regression. RESULTS Among 57,791 patients from 150 practices, 19,837 received systemic treatment within 30 days of death. We observed 36.6% of White patients, 32.7% of Black patients, 43.3% of commercially insured patients, and 37.0% of Medicaid patients received EOL systemic treatment. White patients and those with commercial insurance were more likely to receive EOL systemic treatment than Black patients or those with Medicaid. Treatment at community practices was associated with higher odds of receiving 30-day systemic EOL treatment than treatment at academic centers (adjusted OR, 1.51). We observed large variations in EOL systemic treatment rates across practices. CONCLUSION In a large real-world population, EOL systemic treatment rates were related to patient race, insurance type, and practice setting. Future work should examine factors that contribute to this usage pattern and its impact on downstream care. [Media: see text]

Systemic Anticancer Therapy and Overall Survival in Patients With Very Advanced Solid Tumors

“… a Quintile comparisons were conducted across the 6 cancer types, and a Bonferroni correction was applied to maintain an overall level of significance of α = .05 . All individual tests required an α < .008 for statistical significance.…”

“…Any exploration of why this practice pattern has not changed over time, despite national focus and inclusion in quality-reporting programs, requires addressing the issue of incentives. It is possible that this pattern is partially explained by the adage “you get what you pay for.” Our prior work has shown that there is increasing use of high-cost targeted therapies and immunotherapies at the EOL and that patients who are commercially insured are more likely to receive them than patients who have Medicare/Medicaid . This suggests that economics of reimbursement may contribute to this pattern of care, as commercial insurance often reimburses at 200% to 300% the rate of Medicare …”

“…Multiple studies have shown that except when death is imminent within days, many oncologists struggle to predict when a patient will die . However, the variation in the ASCO-NQF metric seen across practices nationally (risk standardized rate of SACT across all cancer types per 100 patients ranged from 10%-30%) shows that some oncologists are better at this than others, suggesting that this may be a skill that can be learned. Because the present results do not demonstrate a difference in survival between the highest and lowest NQF 0210 quintiles, we cannot rule out the possibility that the lack of difference could be due to an insufficient practice sample size.…”

“…28 As the treatment landscape has evolved to include more effective and less toxic treatments in later lines of therapy, 29,30 any analysis using lines of therapy as a marker would need to control for multiple factors, including median life expectancy for that cancer type (as patients with more indolent cancers will live longer and receive more lines of therapy), the prevalence of cancer types seen within each practice, and which drugs in which lines of treatment are approved at specific time points. Measuring the rate at which a practice uses SACT at the EOL, as NQF 0210 does, has several advantages: (1) it is sufficiently variable to suggest levers for intervention, 8 (2) it has been studied across solid tumor types, 1,2,8,19,31,32 and (3) it is increasingly tracked in national quality and value-based care programs. 25 Any exploration of why this practice pattern has not changed over time, despite national focus and inclusion in quality-reporting programs, requires addressing the issue of incentives.…”

“…Data were analyzed from July 2021 to July 2023. Further description is included in the eMethods in Supplement 1 and in previous publications …”