D. Kerekes1, A. Frey1, S. Khan1, K. Olino1 1Yale University School Of Medicine, New Haven, CT, USA
Introduction:
In an effort to improve the quality of the end of life (EOL) and to decrease healthcare costs, avoidance of chemotherapy at the EOL has been widely recognized as an important quality measure in oncologic care for years. However, since modern immunotherapeutic agents revolutionized the treatment of metastatic melanoma in 2011, prescribing practices near the EOL for these expensive and sometimes morbid treatments have not been given the same attention. This study examines national trends in EOL immunotherapy for patients with stage IV melanoma and describes the cohort of patients subjected to EOL immunotherapy.
Methods:
The National Cancer Database was used to identify patients with stage IV melanoma diagnosed between 2011 and 2017. Initiation of a treatment within one month of death was considered to be EOL treatment. National trends in immunotherapy and in its EOL use were described. Characteristics of the cohort receiving EOL immunotherapy were examined, and factors associated with EOL immunotherapy were identified.
Results:
There were 16,652 stage IV melanoma patients in the study. Overall rate of immunotherapy increased from 15% in 2011 to 54% in 2017 (p<0.001 for trend). The proportion of all patients that received EOL immunotherapy has increased steadily from 0.2% in 2011 to 2% in 2014 to 4% in 2017 (p<0.001). EOL care represented 7% of all immunotherapy treatments in 2017, up from 5% in 2014 and 1% in 2011 (p<0.001). In contrast, the proportion of chemotherapy patients initiating their treatment at the EOL was unchanged over the study time frame (p>0.05). Patients receiving EOL immunotherapy had a mean age of 64.4 years and were predominantly male (73%), from a wealthier zip code (38%), Medicare-insured (52%), and had a Charlson-Deyo comorbidity index of 0 (74%). On risk-adjusted analysis, patients receiving immunotherapy were significantly less likely to receive it at the EOL if they were treated at an academic (OR=0.46, 95% confidence interval = 0.30-0.73, p=0.001) or a network (OR=0.58, 0.35-0.94, p=0.027) facility rather than a community facility, as were patients treated at a high-volume (OR=0.57, 0.43-0.77, p<0.001) rather than low-volume facility. In 2017, 16% of patients receiving immunotherapy at a community facility received it at the EOL, compared to 6% of patients treated at an academic facility. Immunotherapy patients were more likely to receive EOL immunotherapy if they had liver-only metastases (OR=7.41, 2.23-24.62, p<0.001) or two solid organ metastatic sites (OR=9.95, 3.59-27.63, p=0.001) rather than lung-only metastases.
Conclusion:
The share of metastatic melanoma patients that are started on immunotherapy within one month of death is increasing significantly. Treatment at a community or low-volume facility is a risk factor for receipt of EOL immunotherapy. These findings suggest that there may be an opportunity for more judicious prescribing of immunotherapy in the sickest melanoma patients.