Older people with end-stage cancer are often still taking preventive medication during the last year of life, even though they may no longer stand to benefit from these drugs.
Many continue to receive these medications even during the last month of life, according to a Swedish study published online March 25, 2019, in Cancer.
The study results show that in the last month of life 60.1% of individuals received antihypertensives, 14.9% received antidiabetes agents, 48.1% received antithrombotics, 16.8% received lipid modifying agents, and 3.9% received bisphosphonates.
"These drugs are beneficial to the general population, especially elderly people. But in the context of end of life care, preventive drugs [may not be compatible] with the patient's priorities and life expectancy," said first author Lucas Morin, from the Karolinska Institutet in Stockholm, Sweden.
"Many older people with cancer are on an average of four or five preventive drugs near the end if life, and we need to get that number down," he added.
Cancer Mostly a Disease of the Elderly
Among high-income countries, almost two thirds of cancer-related deaths now occur in older people aged 70 or older, the authors note. Because older people often have several chronic medical conditions, many of them already take several preventive medications when they develop cancer.
That's a problem for several reasons: many patients may not live long enough to benefit from preventive medications, anticancer agents can increase the likelihood of drug-drug interactions, advanced age and the cancer itself can increase adverse effects of preventive drugs, and having to pay for drugs that may no longer be beneficial may add to financial burdens near the end of life.
A large number of prescriptions for preventive medications near the end of life may be inappropriate, the authors say. Although some may have a palliative role — bisphosphonates in bone metastases, for instance — the majority will not offer benefit.
"We believe that in 90% of the cases these drugs are unnecessary in end of life care with cancer. At the same time, these drugs have many chances of being risky and harmful," Morin said.
Harms from preventive medications usually appear early, while it takes much longer for patients to reap their benefits.
"These people will live just long enough to experience potential harm, but not long enough to experience benefit," he added.
Patient preferences about the goals of care are vital, he added, even though the conversation may be difficult.
"It's about having a serious conversation with the patient. We need to be very honest with the uncertainty [about length of survival]," he said, "[But] people are much more willing to have discussions about de-prescribing than we give them credit for."
Providers should convey that stopping preventive medications is most often safe, he continued, even though deprescribing may not always be straight forward and requires monitoring. Also, some drugs may be more difficult to deprescribe than others.
"Anticoagulants are much more difficult to de-prescribe because the acute effect of withdrawing the drug can be serious. But there is also a risk, probably a bigger one, of staying on the medication. Antithrombotics are very unlikely to have any benefit for [these] patients, but are very likely to cause serious bleeding," Morin said.
Study Details
For their study, the researchers used data from Swedish national registries to evaluate monthly use and cost of preventive drugs during the last year of life. The analysis included data from 151,201 older adults who had solid tumors and died between 2007 and 2013. These individuals had a mean age at death of 81.3 years, and 60% had been diagnosed with cancer more than 1 year before death. The analysis controlled for sex, age, number of chronic diseases, living arrangement, and education level.
During the last year of life, the number of drugs increased, on average, from 6.9 to 10.1, and the percentage of individuals on 10 or more drugs increased from 26% to 52%.
Median drug costs per person were $1482. Preventive drugs cost $213 per person, and contributed to 20.2% of total drug costs during the last year of life.
Costs varied by type of cancer. Compared with costs for lung cancer (median drug cost, $205), costs were higher for breast cancer ($218), gynecological cancers ($239), and pancreatic cancer ($213).
The authors mentioned several potential limitations. The study had no data on dose changes, and cannot evaluate whether some drugs were tapered off near the end of life. The study could not evaluate the appropriateness of prescribing and whether some preventive drugs were used to treat cancer-related issues. Finally, Sweden has universal healthcare, and the findings may not generalize to countries with more limited access to preventive drugs, such as the United States.
The study was funded by the Swedish Research Council.
The authors have disclosed no relevant financial relationships.
Cancer. Published online March 25, 2019. Abstract
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