Immunotherapy use increasing for metastatic cancers in end-of-life setting

According to a recent study conducted by investigators at the Yale School of Medicine, the initiation of immunotherapy within 30 days of death is increasing over time for patients with metastatic cancers, including renal cell carcinoma (RCC).¹

“Patients with higher metastatic burden and who were treated at nonacademic or low-volume facilities had higher odds of receiving [end-of-life-initiated] immunotherapy," wrote the authors.

“Immunotherapy has revolutionized the field of oncology over the last decade. Because survival is substantially improved for many patients treated with these drugs, its application has increased across the United States. In our study, we focused on immunotherapy initiation at the end of a patient’s life with cancer metastasis,” said senior author Sajid A. Khan, MD, FACS, FSSO, in a news release on the findings.² Khan is an associate professor of surgery and the section chief of hepato-pancreato-biliary and mixed tumors at Yale School of Medicine in New Haven, Connecticut.

In total, the study included 24,625 patients with stage 4 RCC, as well as 20,415 patients with stage 4 melanoma and 197,331 patients with stage 4 non-small cell lung cancer (NSCLC). All patients were treated with immune checkpoint inhibitors from the point of FDA approval through 2019, with the melanoma cohort beginning treatment in 2012 and patients in the RCC and NSCLC cohorts beginning treatment in 2016. The average follow-up for all patients was 13.7 months.

Data showed that immunotherapy utilization in the 30 days preceding death significantly increased among patients in all cohorts. For those with RCC, rates increased from 0.5% to 2.6%. Rates in the melanoma cohort increased from 0.8% to 4.3%, and rates for patients in the NSCLC cohort increased from 0.9% to 3.2%.

In 2019, the end-of-life-initiated treatments with immunotherapy represented 7.3% of all immunotherapy treatments. Further, more than 1 in 14 immunotherapy treatments in 2019 were initiated within 1 month of death.

The authors also noted, “Patients with higher metastatic burden and who were treated at nonacademic or low-volume facilities had higher odds of receiving [end-of-life-initiated] immunotherapy.”¹

Further assessments on the effect of metastasis burden showed that patients who had 3 or more organs involved in metastatic disease were 3.8 times more likely to die within 1 month of immunotherapy initiation compared with those patients who only had lymph node involvement (95% CI, 3.1-4.7; P < .001).

The investigators also noted differences in outcomes depending on the site at which patients received treatment. Treatment at an academic center was associated with a 31% decrease in the risk of death within 1 month of initiating immunotherapy compared with treatment at a nonacademic center (odds ratio, 0.69; 95% CI, 0.65-0.74; P < .001). Similarly, treatment at a high-volume center was associated with a 30% decrease in the risk of death within 1 month of treatment initiation compared with treatment at very low-volume centers (odds ratio, 0.70; 95% CI, 0.65-0.76; P < .001).

The authors concluded that the findings warrant further research on the benefit of immunotherapy in the end-of-life setting for patients with metastatic cancers.

References

1. Kerekes DM, Frey AE, Prsic EH, et al. Immunotherapy initiation at the end of life in patients with metastatic cancer in the US. JAMA Oncol. 2024:e236025. doi:10.1001/jamaoncol.2023.6025

2. Patients less likely to experience death at academic and high-volume hospitals when treated with immunotherapy for metastatic cancers. News release. Yale Cancer Center/Smilow Cancer Hospital. January 4, 2024. Accessed January 8, 2024. https://www.newswise.com/articles/patients-less-likely-to-experience-death-at-academic-and-high-volume-hospitals-when-treated-with-immunotherapy-for-metastatic-cancers