Despite the efforts of health care professionals and advocacy groups, intensive end-of-life care for elderly individuals with metastatic cancer is still common, although treatment has shifted from chemotherapy to immunotherapy, according to recent research. In one study, a majority of older people received aggressive care during their last month of life, which may not reflect their wishes.
Aggressive end-of-life care for elderly people whose cancer cannot be cured can lead to greater pain and other side effects, worse quality of life and delayed palliative care or hospice care—not to mention a heavy financial burden.
As described in JAMA Network Open, Siran Koroukian, PhD, of Case Western Reserve University School of Medicine, and colleagues assessed aggressive end-of-life care for adults ages 66 or older residing in nursing homes or living in the community. Aggressive care was defined as use of cancer-directed treatments (as opposed to therapy to relieve symptoms), more than one emergency room visit or hospital admission during the last month of life, death in a hospital and entering hospice care within the last three days of life.
Using a database of 146,329 older people with metastatic breast, colorectal, lung, pancreas or prostate cancer, the researchers found that nursing home residents were more likely to receive aggressive end-of-life care compared with those living in the community (64% versus 58%, respectively). In many of these cases, hospice care may have been a better option, they suggested.
Nursing home residency was linked to 4% greater likelihood of receiving aggressive end-of-life care, a 6% higher risk of more than one hospitalization and a 61% greater risk of dying in a hospital. On the other hand, nursing home residents were 43% less likely to receiving cancer-directed treatment, 18% less likely to be admitted to an intensive care unit and 11% less likely to enter hospice care during the last three days of life.
“Despite increased emphasis to reduce aggressive end-of-life care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among nursing home residents than their community-dwelling counterparts,” wrote the researchers. “Multilevel interventions to decrease aggressive end-of-life care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.”
Shift to Immunotherapy
In another study, published in JAMA Oncology, Kerin Adelson, MD, of Yale School of Medicine, and colleagues analyzed the use of systemic cancer treatment, such as chemotherapy, targeted therapy or immunotherapy, during end-of-life care.
Systemic cancer treatment at the end of life is known to be linked to increased use of acute care, delayed conversations about end-of-life desires, delayed hospice care, greater cost and worse quality of life and survival. In 2012, the American Society of Clinical Oncology and the National Quality Forum recommended reducing the use of chemotherapy and promoting earlier palliative care for elderly people with cancer. But since then, the use of immunotherapy has grown increasingly common.
The researchers used the Flatiron Health electronic health record database to analyze data for adults who received cancer treatment and died within four years after diagnosis. They found that the overall use of systemic cancer treatment at the end of life remained consistent from 2015 to 2019. Within 30 days of death, 39% of people received systemic treatment, while 17% did so within 14 days of death.
However, the proportion of people who received chemotherapy decreased in favor of immunotherapy. The use of chemotherapy dropped from 26% in 2015 to 16% in 2019, while the use of immunotherapy rose from 5% to 18%. Immunotherapy was especially preferred for people who had advanced non-small cell lung cancer or bladder cancer.
“Approval of multiple new immunotherapy agents has engendered a great replacement phenomenon, substituting immunotherapy for chemotherapy,” wrote the researchers. “This finding requires future research to examine the association of immunotherapy at [the end of life] with downstream acute care use and quality of life in a larger, more representative sample.”
In keeping with these findings, another study published in JAMA Oncology found that there was an inverse relationship between age and survival for cancer patients treated with immunotherapy.
Teja Voruganti, MD, PhD, of the Perelman School of Medicine at the University of Pennsylvania, and colleagues analyzed data from more than 50,000 people with advanced non-small-cell lung cancer who were treated at 280 predominantly community-based U.S. cancer clinics between 2011 and 2019.
Overall use of cancer-directed treatment increased from 69% in 2011 to 77% in 2019. After the approval of the first checkpoint for lung cancer, the use of such drugs rose steeply, from 5% in 2015 to 46% in 2019. The oldest age group was more likely to be treated with checkpoint inhibitors alone.
Median survival increased from 11.5 months to 16.0 months for patients younger than 55, but only from 9.1 months to 10.2 months for those ages 75 or older. People under 55 experienced “clinically meaningful survival gains,” while people ages 75 years or older did not, the study authors concluded.
These findings “may help inform shared decision-making discussions in clinical practice, particularly for the oldest adult age group with non-small-cell lung cancer, Marjory Charlot, MD, of the University of North Carolina Lineberger Comprehensive Cancer Center and Jhanelle Gray, MD, of the H. Lee Moffitt Cancer Center and Research Institute, wrote in an accompanying commentary.
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