According to a study published in Cancer, oncologists display substantial variability in their tendencies to prescribe systemic anticancer therapy for their patients at the end of life, even after consideration of patient-level and practice-level factors.

For this retrospective, observational study, the researchers employed Surveillance, Epidemiology, and End Results–Medicare data from 17,609 patients who died from cancer between 2012 and 2017, their 960 treating oncologists, and the 388 corresponding physician practices.

The authors wrote, “Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life.”

The researchers utilized multilevel models to approximate the oncologists’ rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation.

The study cohort included 17,609 patients, of which 62% had lung cancer, while the remaining patients had colorectal cancer (17%), breast cancer (13%), and prostate cancer (8%). At diagnosis, 53% of the patients were at stage IV cancer, and the median time from diagnosis to death was 15 months (interquartile range [IQR], 7-36) and the median age at death was 74 years (IQR, 69-79). The median Comorbidity Index for patients was 4 (IQR, 2-6).

The results revealed that during their last 30 days of life, patients were less likely to receive systemic therapy if they had a longer duration from diagnosis to death (odds ratio [OR], 0.61; 95% CI, 0.59-0.64; P <.001); had grade 3 tumors (OR, 0.75; 95% CI, 0.62-0.92; P = .005) or grade 4 tumors (OR, 0.68; 95% CI, 0.52-0.89; P = .005); were non-Hispanic black (OR, 0.77; 95% CI, 0.67-0.89; P <.001); had stage IV disease (OR, 0.78; 95% CI, 0.70-0.87; P <.001); were single (OR, 0.87; 95% CI, 0.81-0.93; P <.001); or were older at the time of death (OR, 0.99; 95% CI, 0.98-1.00; P <.001).

Moreover, patients were more likely to receive systemic therapy at the end of life if their year of death was more recent (OR, 1.04; 95% CI, 1.02-1.06; P = .001). Additionally, patients with breast cancer were more likely to receive systemic therapy during their last 30 days compared with those with lung cancer (OR, 1.72; 95% CI, 1.52-1.93; P < .001); however, there were no noteworthy variances in the receipt of systemic therapy among patients with lung, colorectal, and prostate cancers. In an adjusted analysis, patients were significantly more likely to receive end-of-life systemic therapy if their oncologist was in the top 25th percentile for prescribing behavior (high prescribing behavior; OR, 4.42; 95% CI, 4.00-4.89; P <.001) or in the middle 50th percentile (average prescribing behavior; OR, 2.21; 95% CI, 2.02-2.43; P <.001) compared with the bottom 25th percentile (low prescribing behavior).

The results also revealed that when examined by oncologist prescribing behavior, the percentage of patients hospitalized in their last 30 days was 51.9% for the low-prescribing group, 56.2% for the average-prescribing group, and 58.0% for the high-prescribing group. Additionally, the percentage of patients who were either not enrolled in hospice in their last 30 days or were enrolled within 3 days of death was 65.4% for the low-prescribing group, 71.1% for the average-prescribing group, and 75.2% for the high-prescribing group.

“Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies,” the authors concluded.

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