Use of Chemotherapy Near the End of Life

What Factors Matter?

P. Rochigneux; J. L. Raoul; Y. Beaussant; R. Aubry; F. Goldwasser; C. Tournigand; L. Morin

Disclosures

Ann Oncol. 2017;28(4):809-817. 

In This Article

Abstract and Introduction

Abstract

Background: Use of chemotherapy near the end of life in patients with metastatic cancer is often ineffective and toxic. Data about the factors associated with its use remain scarce, especially in Europe.

Methods: Nationwide, register-based study including all hospitalized patients aged ≥20 years who died from metastatic solid tumors in France between 2010 and 2013.

Results: A total of 279 846 hospitalized patients who died from metastatic cancer were included. During the last month before death, 19.5% received chemotherapy (including 11.3% during the last 2 weeks). Female sex (OR= 0.96, 95% CI= 0.93–0.98), older age (OR= 0.70, 95% CI= 0.69–0.71 for each 10-year increase) and higher number of chronic comorbidities (OR= 0.83, 95% CI= 0.82–0.84) were independently associated with lower rates of chemotherapy. Although patients with chemosensitive tumors were statistically more likely to receive chemotherapy during the last month before death (OR= 1.21, 1.18–1.25), this association was mostly fueled by testis and ovary tumors and we found no obvious pattern between the expected chemosensitivity of different cancers and the rates of chemotherapy use close to death. Compared with university hospitals, patients who died in for-profit clinics/hospital (OR= 1.40, 95% CI= 1.34–1.45), or comprehensive cancer centers (OR= 1.43, 95% CI= 1.36–1.50) were more likely to receive chemotherapy. Finally, high-volume centers and hospitals without palliative care units reported greater-than-average rates of chemotherapy near the end of life.

Conclusion: among hospitalized patients with cancer, young individuals, treated in comprehensive cancer centers or in high-volume centers without palliative care units were the most likely to receive chemotherapy near the end of life. We found no evident pattern between the expected chemosensitivity of different cancers and the probability for patients to receive chemotherapy close to death.

Introduction

Over the last two decades, the range of oncological treatments have largely broadened, and considerable progress has been made concerning the efficacy of anticancer treatments.[1] However, during the same period, the aggressiveness of cancer care near the end of life has emerged as a growing concern.[2,3] Many studies reported a significant increase in the use of chemotherapy in the final weeks of life.[4–7] The American Society of Clinical Oncology recommends to avoid the use of chemotherapy near the end of life due to the absence of evidence supporting its clinical value.[8] Furthermore, the risk of adverse events related to chemotherapy is amplified by malnutrition, immunosuppression and sarcopenia, with an increased probability of acute toxicity and a negative impact on the patients' quality of life.[9] Chemotherapy in patients with poor performance status is also associated with higher odds of dying in acute care hospitals and with less frequent hospice use, which can both be detrimental to the patients' wellbeing.[10,11] The financial impact of active treatments near the end of life has also come under great scrutiny.[12,13]

Prior studies reported rates of chemotherapy use ranging from 5% to 55% in the last month before death.[14–16] Many factors have been found to be associated with chemotherapy near the end of life, including sociodemographic characteristics, clinical parameters and environmental factors (e.g. type of hospital, specialty of the physician, geographical inequalities, funding scheme). However, these studies were often mono-center, dedicated to a single tumor site or a specific subgroup of patients or institutions. There is therefore a need for a more precise examination of the factors associated with chemotherapy at the end of life, in order to identify situations of potential over-treatment.

This study aimed to examine patient-level, tumor-related and facility-level factors associated with the use of chemotherapy in the final months before death. We hypothesized that, while controlling for potential confounders, having a chemosensitive tumor and being treated in a tertiary care facility (university hospital or comprehensive cancer center) were associated with higher odds of receiving chemotherapy near the end of life.

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