Despite advances in cancer screening and detection, many cancers are not diagnosed until after they have metastasized. In patients with aggressive malignancies or severe comorbidities, survival can be limited. There has been relatively little information about treatment and outcomes in this population. To better understand treatment patterns in patients with poor prognosis, a study of the National Cancer Database evaluated treatment patterns in 100,848 patients with de novo metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis.
Overall, this study found that many patients with limited survival received fairly aggressive therapeutic interventions that would likely impair quality of life during their limited survival time. From 2004 through 2014, surgery of primary tumor for colorectal cancer and breast cancer, chemotherapy and radiation treatment for lung cancer and breast, and chemotherapy for pancreatic cancer steadily decreased among patients who survived for less than 1 month after their de novo metastatic cancer diagnosis. The majority of these patients (73%) did not receive chemotherapy, radiation, or surgery before their death. Nonetheless, there were wide variations in treatment patterns by institution type. Patients with lung cancer treated at community practices had a 40% lower chance of receiving surgery and a 48% lower chance of being treated with radiotherapy than those treated at a National Cancer Institute (NCI) cancer center. However, this could be biased by factors such as referral of poor-prognosis patients to academic centers for clinical trials. Older age, presence of comorbidities, and lack of insurance were factors most strongly associated with receiving no interventional treatment. Patients who lacked insurance had 35% to 56% lower odds of initiating chemotherapy for any tumor type, suggesting a socioeconomic component to treatment decisions.
High Altitude: This study provides important insight into factors that might influence treatment decisions in patients with de novo metastatic cancer and poor prognosis. Although this study lacked important information that would be helpful in further evaluating treatment decision-making in these patients (eg, performance status, symptoms, patient preferences, palliative treatments, treatment-related toxicity, and ultimate cause of death), several interesting factors influencing treatment were identified. These included tumor type, treatment facility (NCI institution or other), and insurance status. This study provides important insights into factors that might influence therapy decisions in patients with cancer and poor prognosis, and further studies are needed to better define the benefit:risk propositions of current therapeutic interventions for patients diagnosed with de novo metastatic aggressive cancers. In the short term, the data highlighting differences in practice patterns between community and academic settings may be valuable, and underscore a need for increased collaboration and standardization of treatment selection.
Ground Level: The information gained from these data highlight the importance of identifying patients with de novo metastatic cancer that is imminently fatal and stratifying patients for aggressive treatment or hospice care. This study suggests that many patients with little likelihood of benefit are receiving therapeutic interventions that might undermine the quality of their end-of-life weeks. However, additional studies that more carefully evaluate patient and disease factors influencing treatment outcomes will be needed. One important observation in this study is the disparity in utilization of therapeutic interventions among patients with private insurance vs other patients. Although this study did not determine whether one group was being overtreated and the other undertreated, it will be important to follow this trend, with the goal that all patients receive the optimal care possible in all settings.