An analysis of use of systemic anticancer treatment within 30 days and 14 days before death across all cancer types combined did not change in recent years. However, the type of systemic treatment received has changed. The investigators found overall decreases in chemotherapy alone and increases in immunotherapy use. These results mostly reflect the patterns in advanced non–small cell lung cancer (NSCLC) and urothelial cancers with increased use of immune checkpoint inhibitors. In metastatic breast cancer, renal cell carcinoma, and colorectal cancer there were slight decreases in overall use of systemic anticancer treatment at end-of-life, but there was almost no change for pancreatic cancer. Findings from data retrieved in the nationwide Flatiron Health electronic health record–derived database were published by Dr. Kerin B. Adelson of the Yale School of Medicine in New Haven, CT, US and colleagues in a research letter on 20 October 2022 in the JAMA Oncology.

The authors wrote in the background that use of systemic anticancer treatment at end-of-life is associated with increased acute care use, delayed goals of care conversations, late hospice enrolment, higher costs, and possibly adverse quality and duration of life. In 2012, the American Society of Clinical Oncology and the National Quality Forum developed the quality measure Proportion Receiving Chemotherapy in the Last 14 Days of Life to promote reduction in chemotherapy and earlier integration of palliative care at end-of-life.

Since 2012, the systemic anticancer treatment landscape has changed due to approvals of multiple new targeted treatments. Recent studies showed increasing use of immune checkpoint inhibitors end-of-life in patients with metastatic urothelial cancer, NSCLC and melanoma, despite no evidence that this practice is associated with improved outcomes.

However, previous studies were limited to specific cancer types and unable to associate end-of-life treatment rates with exact date of death. It prompted the study team to analyze patterns in systemic anticancer treatment near end-of-life across all cancer deaths, between 2015 and 2019, to understand changes in use of chemotherapy and targeted treatments.

The primary outcome was systemic anticancer treatment use at 30 days and 14 days before death. The study team assessed treatment subcategories and examined treatment rates at end-of-life across the 6 most common cancer types within each treatment subcategory.

The study investigators identified no difference in overall use of systemic anticancer treatment at end-of-life since 2015. They commented that approval of multiple new immunotherapy agents has produced a great replacement phenomenon, substituting immunotherapy for chemotherapy. Although chemotherapy rates have declined, increases in use of targeted treatments may have interfered with achieving the goal of earlier palliative care integration or reduction in acute care use.

The authors also commented that findings from one study that any systemic anticancer treatment at end-of-life, including immunotherapy, is associated with higher rates of downstream acute care, delayed hospice care, and higher costs, requires future research to examine the association of immunotherapy at end-of-life with downstream acute care use and quality-of-life in a larger, more representative sample.

This study was sponsored by Flatiron Health Inc, an independent subsidiary of the Roche Group.


Canavan ME, Wang X, Ascha MS, et al. Systemic Anticancer Therapy at the End of Life—Changes in Usage Pattern in the Immunotherapy Era. JAMA Oncology; Published online 20 October 2022. DOI: 10.1001/jamaoncol.2022.4666