Immune Checkpoint Inhibitors May Have Been Used Inappropriately in Half of Study Patients with Advanced Cancer Who Were Near the End of Life

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced cancer and been shown to extend progression-free survival and overall survival in patients with a variety of cancers. In part because of the increasing use of ICIs, the systemic treatment of patients with advanced cancer who are near the end of life (EOL) has been increasing. However, data on additional factors associated with this trend are limited. 

To better characterize adult patients who received an ICI dose within the last 30 days of life, researchers queried the University of Florida Health Cancer Center’s EPIC electronic medical record system to retrospective identify such patients, then manually reviewed their charts to collect data on several key characteristics (JCO Oncol Pract. 2022; Published online March 7. doi:10.1200.OP.21.00689). All of the 97 patients whose charts they evaluated died within 30 days of receiving a dose of ICI during a continuous 4-year period from April 2015 through April 2019.

“To our knowledge, this is the first study that comprehensively characterized a substantial number of patients with associated relevant variables such as ECOG PS [Eastern Cooperative Oncology Group performance status], rates of hospitalization and intensive care unit (ICU) stays, and other clinical factors in those patients receiving ICIs in the last 30 days of life,” wrote Matthew Bloom, MD, College of Medicine, University of Florida, Gainesville, FL, and colleagues.

The study revealed that more than 60% of the patients were hospitalized, 65% visited the emergency department, 20% needed to be admitted to the ICU, and 25% died in the hospital. Moreover, 40% received only a single dose of ICI in the 30 days before they died. “[T]he beneficial anticancer effects of treatment can take months, and patients at the EOL may not live long enough to derive the benefit. ICIs also come with the risk of immune-related adverse events, which can be life-threatening,” Dr Bloom and team noted.

“Similar to studies with chemotherapy at EOL, our study corroborates data where patients receiving ICIs in the last 30 days of life had high rates of resource utilization, dying in the hospital setting, and low hospice enrollment,” they added. 

They also noted a steady upward trend in the use of ICIs at EOL from year to year during the study period ending in 2019. On the basis of this finding, they speculated that ICI use in these patients may be even more common today.

In addition, they found that many patients had a poor ECOG PS when the last dose of ICI was given; 50% had an ECOG PS of at least 2 and 17% had an ECOG PS of 3. 

“While accurate predictions regarding the EOL are challenging, oncologists routinely use clinical factors such as ECOG PS along with patient preferences to guide recommendations and shared decision making. Our findings may support oncologists in their conversations with patients and provide reassurance that for some patients, transitioning to palliative and supportive care may be in their best interest,” the researchers concluded.