ABSTRACT
BACKGROUND: Immune checkpoint inhibitors (ICIs) can lead to durable responses in patients with lung cancer but may delay transitions to hospice at the end of life (EOL). We aimed to test the association of continuity of care with EOL outcomes in the ICI era. METHODS: We collected retrospective data on all patients with lung cancer who started ICI treatment at a single comprehensive cancer center in the United States (1/1/14-5/1/18) and subsequently died. We defined a hospice referral as having continuity of care if placed by a provider from the patient's multidisciplinary cancer team (e.g., a medical oncologist, palliative care specialist, intensivist, and hospitalist). RESULTS: In this cohort of 143 patients, 58% had a team-based hospice referral which was associated with a lower risk of death in the hospital. The most common reason patients declined hospice at EOL was an unwillingness to discontinue cancer-directed therapy. As compared to a similar historical cohort of patients treated with chemotherapy alone (2008-2010), there was a similar rate of hospice referral (68% vs 74%) but higher rates of new systemic therapy initiated within 30 days of death (17% vs 6%, p .001) and last dose within 14 days of death (13% vs 5%, p .005). CONCLUSIONS: Future studies should test the continuity of care at EOL as a new quality metric for advanced NSCLC.
Subject(s)
Hospice Care , Hospices , Lung Neoplasms , Neoplasms , Terminal Care , Humans , United States , Retrospective Studies , Palliative Care , Lung Neoplasms/drug therapy , Referral and Consultation , Neoplasms/therapy , ImmunotherapyABSTRACT
INTRODUCTION: Immunotherapy has become a key treatment for patients with advanced non-small-cell lung cancer (NSCLC). While a survival advantage has been proven for patients who are medically fit, it is unknown whether a benefit exists for patients with poor performance status (PS). PATIENTS AND METHODS: We performed a retrospective analysis of NSCLC patients who received immunotherapy in our health system. Age and PS at the time of initial immunotherapy administration were assigned based on physician documentation. Radiographic response and date of progression were assigned according to the treating physician's assessment and confirmed by the study team. Immune-related adverse events were extracted from records. RESULTS: We identified 285 NSCLC patients who received immunotherapy between January 2014 and April 2018. In this group, 153 patients (53.7%) had PS 0-1, 114 (40.0%) had PS 2, and 18 (6.3%) had PS 3. Response rates were similar across PS groups with 26.6% for PS 1, 25.2% for PS 2, and 23.1% for PS 3 (P = .95). Survival outcomes varied with pretreatment PS. For PS 0-1, PS 2, and PS 3, median overall survival was 14.7, 8.3, and 1.5 months (P < .001), and progression-free survival was 7.4, 5.1, and 1.3 months (P < .001). Patients aged < 70 had a lower rate (7.6%) of immune-related adverse events requiring steroids compared to patients ≥ 70 (15%) (P = .04). CONCLUSION: Patients with poor baseline PS demonstrate similar response rate but inferior progression-free survival and overall survival compared to medically fit patients. Prospective trials are needed to optimize treatment for this large population.
Subject(s)
Carcinoma, Non-Small-Cell Lung/mortality , Immunotherapy/mortality , Lung Neoplasms/mortality , Adult , Age Factors , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/immunology , Carcinoma, Non-Small-Cell Lung/pathology , Carcinoma, Non-Small-Cell Lung/therapy , Female , Follow-Up Studies , Humans , Lung Neoplasms/immunology , Lung Neoplasms/pathology , Lung Neoplasms/therapy , Male , Middle Aged , Prognosis , Retrospective Studies , Survival RateABSTRACT
A 26-year-old man with history of extensive tophaceous gout presented to the referring facility with decreased bilateral lower extremity sensation and motor function that began acutely 1 week prior to admission and had progressed to urinary incontinence. The patient was admitted to the intensive care unit due to concern for sepsis secondary to epidural abscess. The patient was started on empiric vancomycin and cefepime. Neurosurgery did not recommend acute neurosurgical intervention given the lack of a compressive lesion. Aspiration of the paraspinal collection by interventional radiology subsequently showed crystals consistent with tophaceous gout. Given the high initial suspicion for gout and results of the paraspinal aspiration, the patient was started on prolonged steroid taper as well as allopurinol and colchicine. The patient eventually had partial neurological recovery with discharge to an inpatient rehabilitation facility for further physical therapy rehabilitation.
