Some patients who had been newly diagnosed with metastatic cancer and who died within 1 month of their diagnosis received aggressive but ineffective treatment during that brief period, according to new findings.
However, there were marked variations in treatment by cancer type, patient age, insurance coverage, and type of treatment facility.
For example, the investigators found that among more than 100,000 patients, 12.5% of those with pancreatic cancer, 29% of those with lung cancer, 34.9% of those with breast cancer, and 37.2% of those with colorectal cancer received at least one type of treatment despite their de novo metastatic cancer diagnosis.
The authors found that the odds of receiving chemotherapy were lower for older patients regardless of cancer type. Older patients with lung cancer were less likely to receive radiotherapy.
The odds of receiving chemotherapy and radiotherapy were also lower for lung and pancreatic cancer patients who had higher comorbidity scores. Among uninsured patients, the odds of receiving chemotherapy were lower for those with lung cancer or breast cancer. The type of treatment modalities offered varied considerably by facility type.
Because the data were drawn from a database, the authors were unable to determine why some patients underwent treatment and others did not.
"Determining appropriateness of care for these patients is very difficult, as they are a unique population who die soon after being newly diagnosed with metastatic cancer," said lead author Helmneh Sineshaw, MD, MPH, principal scientist, Health Services Research, American Cancer Society.
"The decision to administer aggressive treatment needs better prognostication to guide care decisions and should involve physicians, patients, and their families," he told Medscape Medical News. "We need better prognostication for patients with imminently fatal de novo metastatic cancer to guide care decisions and avoid unnecessary aggressive and expensive therapies."
The study was published online April 15 in JNCI Cancer Spectrum.
De novo metastatic diseases account for a substantial proportion of the mortality related to lung, colorectal, breast, and pancreatic cancers. These four cancers are among the leading causes of cancer-related death in the United States, and even with advances in treatment, many patients in the population die soon after receiving their diagnosis.
However, note the authors, the appropriateness and quality of care is difficult to determine in this patient population, and treatment patterns have not been well characterized.
Variations Across Cancer Types
For their study, Sineshaw and colleagues identified 100,848 adult patients in the National Cancer Data Base with de novo metastatic lung, colorectal, breast, or pancreatic cancer who had been diagnosed from 2004 to 2014 and who died within 1 month of diagnosis. They evaluated the use of surgery, chemotherapy, radiotherapy, and hormonal therapy in this population in an effort to provide "real-world" information on patterns of care among patients who died soon after receiving their diagnosis.
Within the cohort, 66.5% of patients had lung cancer, 18% had pancreatic cancer, 12% had colorectal cancer, and 3.6% were women with breast cancer. More than three quarters of the patients (77%) were white, 44% were aged 75 years or older, and 60% received treatment at facilities in which there was a high volume of de novo metastatic cancer cases. Of patients with a comorbidity score ≥2, lung cancer accounted for the highest percentage (21%).
Receipt of treatment varied by cancer type. Of patients who received at least one type of treatment, 12.5% had pancreatic cancer, 29% had lung cancer, 34.9% had breast cancer, and 37.2% had colorectal cancer; 72.6% did not receive any type of cancer-directed therapy.
The use of the different types of cancer-directed therapy varied considerably by cancer type. For example, surgery was most commonly used for patients with colorectal cancer (28.3%); it was least commonly used for patients with pancreatic cancer (0.4%). Use of chemotherapy ranged from 5.8% for patients with colorectal cancer to 11.3% for patients with lung or breast cancer; 18.7% of lung cancer patients received radiotherapy, compared to 1.3% of those with pancreatic cancer.
In a supplemental analysis, the authors found that chemotherapy was relatively commonly used among patients diagnosed with small cell lung cancer (27%); 23.9% of women with hormone receptor–positive breast cancer received hormonal therapy.
Patient Factors Play a Role
Sineshaw and colleagues also assessed other factors that could influence the likelihood of receiving aggressive treatment. Such treatment also varied with respect to type of treatment and type of cancer. Older lung cancer patients (those aged 75 years or older) had 46% to 70% lower odds of receiving radiotherapy and 77% to 92% lower odds of receiving chemotherapy compared to younger patients (those aged 18 to 39 years). Among patients with breast cancer, older patients had 65% to 99% lower odds of receiving chemotherapy compared to younger patients.
For patients with high comorbidity scores (2+), those with pancreatic cancer had 25% lower odds of receiving chemotherapy compared with those who had no comorbid conditions; patients with lung cancer who had a high comorbity score had 33% lower odds of receiving radiotherapy.
Insurance also played a role. Uninsured patients had 47% lower odds of undergoing surgery for a primary tumor for colorectal cancer and 14% lower odds of receiving radiotherapy for lung cancer. For each cancer type, the odds were 35% to 56% lower for receiving chemotherapy.
During the study period, for patients with colorectal cancer or breast cancer, the use of surgery of the primary tumor declined steadily. For patients with lung cancer or breast cancer, use of chemotherapy and radiotherapy also steadily declined, as did use of chemotherapy for patients with pancreatic cancer (for all, P trend < .01).
In addition, the authors found that there were variations of treatment modalities according to the type of facility in which care was delivered.
"Multiple factors could influence the decision to treat or not to treat these patients with a goal of prolonging life," said Sineshaw. "Our findings highlight that more research is needed to specifically identify patients with imminently fatal metastatic cancer who will not benefit from attempted life-prolonging treatment, as those who received treatment died soon after diagnosis."
The study was supported by the American Cancer Society Intramural Research and National Institutes of Health/National Cancer Institute. Sineshaw has disclosed no relevant financial relationships.
JNCI Cancer Spectr. Published online April 15, 2019. Abstract
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