End-of-Life Cancer Care Varies by Race, Insurance, Setting

TOPLINE:

Patient's race, insurance type, and practice setting were associated with the use of systemic cancer therapy at the end of life (EOL), differences potentially attributable to inequities rather than efforts to improve quality of care.

METHODOLOGY:

The nationwide Flatiron Health electronic health record database was used to identify 53,791 patients from 150 practices diagnosed with advanced or metastatic cancer after 2011 who died between January 2015 and January 2020.
Among these patients, 19,837 received systemic treatment within 30 days of death.
Key demographic and clinical characteristics included patient age, race, insurance type, and practice setting.
Researchers divided treatments into categories including chemotherapy alone, combination chemotherapy and immunotherapy, and immunotherapy with and without targeted therapy.

TAKEAWAY:

White patients were significantly more likely to receive treatment within 30 days of death compared with Black patients (36.6% vs 32.7%).
Commercially insured patients were significantly more likely to receive end-of-life systemic cancer treatment within 30 days of death compared with those covered by Medicare or Medicaid (43.3% vs 37.3% and 37%).
Patients treated at community practices were also significantly more likely to receive end-of-life systemic therapy than those treated at academic centers (37% vs 34%).
White patients were more likely to receive any end-of-life systemic treatment compared with Black patients (adjusted odds ratio [aOR], 0.85), especially immunotherapy ± targeted therapy (aOR, 0.86).

IN PRACTICE:

"Although our results seem to suggest better [end-of-life] quality of care among Black patients and those with Medicaid and Medicare insurance, it is essential to point out that this difference may be due to structural inequities rather than intentional efforts to improve quality of care in these groups," the authors write. The findings could be attributable to several factors "including the economics of reimbursement, inequities in treatments offered or requested, and differences in communication between providers and patients on the basis of race."

SOURCE:

The study, led by Maureen Canavan, PhD, with the Yale School of Medicine, New Haven, was published June 20 in the Journal of Clinical Oncology, alongside an accompanying editorial, from Holly G. Prigerson, PhD, of Weill Cornell Medicine, and Alfred I. Neugut, MD, PhD, Columbia University, both in New York City.

LIMITATIONS:

The study did not include patient or clinician preferences and thus did not consider whether end-of-life care aligned with patients' wishes. The Flatiron network has a higher percentage of community practices than hospital-based health systems, which may have underrepresented therapy given in the inpatient setting.

DISCLOSURES:

This study was supported by Flatiron Health Inc. Authors disclosed relationships with Flatiron Health, Roche, Plinth Analytics, Grand Rounds, Artera, Pfizer, Johnson & Johnson (Inst), AstraZeneca (Inst), Genentech and others. No other potential conflicts of interest were reported.

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