Duration of palliative care involvement and immunotherapy treatment near the end of life among patients with cancer who died in-hospital

The Role of Palliative Nursing in the Context of Immunotherapies: A Scoping Review of Patient- and Family-Centered Care Considerations

Immunotherapies are increasingly used to treat advanced cancers and can extend survival in some patients. The potential for longer survival may inflate prognosis expectations among patients and caregivers and delay palliative care. This review sought to identify issues impacting patients and caregivers that influence specialized palliative care use in the context of immunotherapies. A scoping review was conducted with guidance from the JBI Manual for Evidence Synthesis. Studies were identified using MEDLINE, EMBASE, CINAHL Complete, AgeLine, Cochrane Library, and APA PsycINFO, without any database filters or limiters. Inclusion criteria included palliative care utilization among adult cancer patients receiving immunotherapy and their family caregivers in any geographical or specialty setting. The protocol was registered in the Open Science Framework. Using Covidence, 11 898 studies were screened by reviewers, with 10 studies meeting inclusion criteria. Themes of patient and family considerations that affect the use of specialized palliative care included (1) understanding of disease/treatment, (2) hope/optimism, (3) communication barriers, and (4) emotional distress and uncertainty. This review is one of the first to identify issues impacting patients receiving immunotherapies and their families. Findings have implications for nurse communication, education, and psychosocial support with advanced cancer patients and families receiving immunotherapies.

Systemic anticancer therapy at the end of life: real-world insights from a tertiary oncology center in Israel

BACKGROUND

Aggressive end-of-life (EOL) care, such as systemic anticancer therapy (SACT) for advanced cancer patients, represents a potential indicator of low-quality care that may deviate from the primary palliative objective of treatment.

METHODS

A retrospective study analyzed consecutive patients with advanced cancers treated at a tertiary oncology center in Israel from January 2019 to December 2022. Demographic and clinical data were examined, with a focus on intravenous (IV) oncologic treatment administration rates at 30 and 90 days before death.

RESULTS

The study included 1851 patients who received IV oncologic medications and died during 2019-2022. The median age at death was 69 years, with 51.3% (951) being men. Systemic anticancer therapy administration rates were 36% (666 patients) in the last 30 days and 67.6% (1252 patients) in the last 90 days prior to death. Chemotherapy was the most common EOL medication (58%). Higher EOL SACT rates were associated with younger age, better ECOG performance status, shorter disease duration, and specific tumor origins, particularly breast cancer. Conversely, gender, marital status, and ethnicity showed no significant correlation with EOL treatment use.

DISCUSSION

Our data provide insight into current practice adopted by healthcare professionals regarding EOL treatment administration in Israel. A positive EOL experience is a significant goal in the oncology clinic, yet our findings demonstrate high rates of aggressive EOL care and may highlight the necessity for regulatory and educational changes within the healthcare system.

Impact of immunotherapy on the care patterns and outcomes of patients with advanced hepatocellular carcinoma

BACKGROUND

Modern immunotherapy with checkpoint inhibitors revolutionized cancer treatment and outcomes. This study aims to demonstrate how immunotherapy has impacted the national landscape of systemic treatment and palliative care in advanced hepatocellular carcinoma (HCC).

METHODS

Retrospective cohort selecting patients from the U.S.-based National Cancer Database (NCDB) with clinical stages T3b/T4 and stage IV HCC from 2010 to 2021. We performed a multivariable analysis using the Cox proportional hazard for overall survival (OS) comparisons and a logistic regression model to study immunotherapy use.

RESULTS

Immunotherapy use increased from 0.27 % in 2010 to 33.80 % in 2021. The median OS survival (in months) was 2 for untreated patients, 7.20 for chemotherapy, and 7.46 for immunotherapy. There was a better OS with immunotherapy (HR 0.59, 95 % CI 0.56-0.62). Systemic therapy for palliation increased from 14.41 % in 2010 to 25.32 % in 2021. Compared to surgical palliation, radiation (HR 0.61, 95 % CI 0.52-0.71) and systemic palliative (HR 0.59, 95 % CI 0.51-0.69) therapies improved OS.

CONCLUSION

From 2010 to 2021, there was a significant increase in the use of immunotherapy, parallel to a large shift toward systemic therapy use for palliative care in patients with advanced HCC. Immunotherapy was associated with a significant OS benefit in the palliative setting.

Increasing challenges of general practitioner-oncologist interaction in end-of-life communication: a qualitative study

BACKGROUND

The timely initiation of end-of-life (EOL) conversations is considerered best practice for patients with advanced cancer and therefore recommended in oncological guidelines. General practitioners (GPs) play a key role in the coordination of EOL-care and often claim that they have also the responsibility to initiate the necessary conversations. Nonetheless, the content of these conversations is rarely a subject of communication between GPs and oncology specialists but crucial for timely integration of palliative care. The aim of this study is to explore the GPs' perspectives on initiation and conduction of EOL-conversations in patients with metastatic lung cancer and how they perceive the interaction with the oncologists of a cancer center.

METHODS

Qualitative design with in-depth interviews with GPs that refer patients with metastatic lung cancer to a cancer center; thematic analysis following Braun and Clarke.

RESULTS

We identified three main themes: timing and conduction of EOL-conversations, factors influencing EOL-conversations, and modes of GP-oncologist interaction. All themes showed important and increasing challenges in regard to communication strategies or procedures within the cancer center and between general practitioners and oncologists. Aside from the elucidated challenges of EOL-communication, new problems arise from the difficulties in keeping pace with advances in oncology and the increasing prognostic uncertainty. Additionally, the lack of standardized communication in EOL-topics between GPs and oncologists is underlined. Options in the mode of interaction include written information in reports or digital platforms and direct phone calls.

CONCLUSIONS

Because of the growing complexity in modern oncology, strategies for improvement in GP-oncologist interaction have to consider information about therapeutic advances and prognosis of patients. The increasing prognostic uncertainty hazards the adequate provision and conduction of EOL-conversations and thus, the timely integration of palliative care. As a consequence, a trustful personal interaction that includes direct contact via phone calls between GPs and oncologists should be encouraged.

Real-life effectiveness on overall survival of continued immune checkpoint inhibition following progression in advanced melanoma: estimation from the Melbase cohort

The link between palliative care and oncology must continue to develop, taking into account advances in treatment.Immune checkpoint inhibition (ICI) for metastatic melanoma is associated with different types of response, making it difficult to assess the benefits to the patient. Some clinical trials suggest a survival advantage of ICI even in the absence of an objective radiographic response. The aim of this study is to assess the impact of continuing ICI after progression of the disease on the overall survival (OS) in a cohort of final-line metastatic melanoma patients. Clinical data from 120 patients with metastatic melanoma were collected via Melbase, a French multicentric biobank, prospectively enrolling unresectable melanoma. Two groups were defined: patients continuing final-line ICI at progression (treated) and patients stopping ICI at progression (controls). The primary end-point is the OS from progression. Propensity score weighting was used to correct for indication bias. From the 120 patients, 72 (60%) continued ICI. Median OS from progression was 4.2 months [95% confidence interval (CI) 2.6-6.27] in the treated group and median OS was 1.3 months (95% CI 0.95-1.74) in the control group ( P  < 0.0001). The calculated hazard ratio was 0.20 (0.13-0.33). Continued ICI was discovered to have an association with a higher rate of hospitalization at the end of life; more treatments received in the last 15 days of life and less utilization of specialist palliative care. This study discovered that patients with metastatic melanoma show a significant decrease in the instantaneous probability of mortality when they continue with finale-line ICI after progression.

Immunotherapy Initiation at the End of Life in Patients With Metastatic Cancer in the US

Importance

While immunotherapy is being used in an expanding range of clinical scenarios, the incidence of immunotherapy initiation at the end of life (EOL) is unknown.

Objective

To describe patient characteristics, practice patterns, and risk factors concerning EOL-initiated (EOL-I) immunotherapy over time.

Design, Setting, and Participants

Retrospective cohort study using a US national clinical database of patients with metastatic melanoma, non-small cell lung cancer (NSCLC), or kidney cell carcinoma (KCC) diagnosed after US Food and Drug Administration approval of immune checkpoint inhibitors for the treatment of each disease through December 2019. Mean follow-up was 13.7 months. Data analysis was performed from December 2022 to May 2023.

Exposures

Age, sex, race and ethnicity, insurance, location, facility type, hospital volume, Charlson-Deyo Comorbidity Index, and location of metastases.

Main Outcomes and Measures

Main outcomes were EOL-I immunotherapy, defined as immunotherapy initiated within 1 month of death, and characteristics of the cohort receiving EOL-I immunotherapy and factors associated with its use.

Results

Overall, data for 242 371 patients were analyzed. The study included 20 415 patients with stage IV melanoma, 197 331 patients with stage IV NSCLC, and 24 625 patients with stage IV KCC. Mean (SD) age was 67.9 (11.4) years, 42.5% were older than 70 years, 56.0% were male, and 29.3% received immunotherapy. The percentage of patients who received EOL-I immunotherapy increased over time for all cancers. More than 1 in 14 immunotherapy treatments in 2019 were initiated within 1 month of death. Risk-adjusted patients with 3 or more organs involved in metastatic disease were 3.8-fold more likely (95% CI, 3.1-4.7; P < .001) to die within 1 month of immunotherapy initiation than those with lymph node involvement only. Treatment at an academic or high-volume center rather than a nonacademic or very low-volume center was associated with a 31% (odds ratio, 0.69; 95% CI, 0.65-0.74; P < .001) and 30% (odds ratio, 0.70; 95% CI, 0.65-0.76; P < .001) decrease in odds of death within a month of initiating immunotherapy, respectively.

Conclusions and Relevance

Findings of this cohort study show that the initiation of immunotherapy at the EOL is increasing over time. Patients with higher metastatic burden and who were treated at nonacademic or low-volume facilities had higher odds of receiving EOL-I immunotherapy. Tracking EOL-I immunotherapy can offer insights into national prescribing patterns and serve as a harbinger for shifts in the clinical approach to patients with advanced cancer.