Use of chemotherapy near the end of life (EOL) for solid cancer patients is usually ineffective and toxic. Data about the factors associated with its use remain scarce, especially in Europe.
We designed a nationwide, register-based study including all hospitalized patients aged ≥20 years who died with metastatic solid tumors in France between 2010 and 2013. Multivariate analyses were performed to identify patients, tumor and facility level characteristics associated with chemotherapy use. Specific sub-analyses were also computed to investigate the role of the supposed tumors' chemosensitivity (defined by the tumors response rate to first line chemotherapy).
279,846 metastatic solid cancers were included. Chemotherapy rates near the EOL were 39.1% (last 3 month), 19.5% (last month), 11.3% (last 2 weeks). During their last month of life, 6.6% of patients started or resumed a chemotherapy regimen. In multivariate analysis, female sex (OR = 0.96, 0.93-0.98), older age (OR = 0.70, 0.69-0.71 for each 10-year increase) and higher number of chronic comorbidities (OR = 0.83, 0.82-0.84) were independently associated with lower rates of chemotherapy. Tumor chemosensitivity was positively associated with the odds of receiving chemotherapy during the last month of life (OR= 1.21, 1.18-1.25). Patients with a cancer for which a major therapeutic innovation occurred between 2005-2010 were also more likely to receive chemotherapy (OR = 1.17, 1.14-1.20). Compared with university hospitals, patients who died in for-profit hospitals (OR= 1.40, 1.34-1.45), and comprehensive cancer centers (OR= 1.43, 1.36-1.50) were more likely to receive chemotherapy. Finally, high-volume centers and hospitals without palliative care units reported greater-than-average rates of chemotherapy near the end of life.
Chemotherapy rates near the EOL for metastatic solid cancers patients are high, especially in young patients, treated in high-volume centers, without palliative care unit. To decrease the aggressiveness of EOL treatments, there is an urgent need to develop early palliative care, to reinforce supportive care training for oncologist, and to implement clear EOL care guidelines.
Clinical trial identification
Legal entity responsible for the study
ATIH : Agence technique de l'information sur l'hospitalisation
Paoli Calmette Institute, Marseille Aging Research Center, Karolinska Institutet, Stockholm
All authors have declared no conflicts of interest.