Background: To the authors' knowledge, end-of-life (EOL) care outcomes among adolescents and young adults (AYAs) with cancer who are living in poverty remain poorly understood. The primary aim of the current study was to examine the effect of poverty on EOL care for AYA patients with cancer.
Methods: The authors conducted a multisite, retrospective study of AYA patients with cancer aged 15 to 39 years who died between January 2013 and December 2016 at 3 academic sites. Medical record-based EOL care outcomes included hospice referral, palliative care (PC) consultation, cancer treatment within the last month of life, and location of death. Two measures of poverty were applied: 1) zip code with a median income =200% of the federal poverty level; and 2) public insurance or lack of insurance. Logistic regression analyses were conducted.
Results: A total of 252 AYA cancer decedents were identified. Approximately 41% lived in a high-poverty zip code and 48% had public insurance or lacked insurance; approximately 70% had at least 1 poverty indicator. Nearly 40% had a hospice referral, 60% had a PC consultation (76% on an inpatient basis), 38% received EOL cancer treatment, and 39% died in the hospital. In bivariable analyses, AYA patients living in low-income zip codes were found to be less likely to enroll in hospice (P = .01), have an early PC referral (P = .01), or receive EOL cancer treatment (P = .03), although only EOL cancer treatment met statistical significance in multivariable models. No differences with regard to location of death (P = .99) were observed.
Conclusions: AYA patients with cancer experience low rates of hospice referral and high rates of in-hospital death regardless of socioeconomic status. Future studies should evaluate early inpatient PC referrals as a possible method for improving EOL care.
Background: Immune checkpoint inhibitors (ICIs) have revolutionized treatment for many patients with advanced cancer. Little is known about ICI use near the end of life.
Objective: To describe ICI use near the end of life.
Design: Retrospective study of patients who received ICIs and died.
Setting/Subjects: Patients treated with ICIs who died between August 2014 and December 2018 (N = 441) at the University of Iowa.
Measurements: Comparisons were made between patients who received ICIs =30 days versus patients who received ICIs >30 days before death. The same analysis was done using a cutoff of 90 days.
Results: Two hundred ninety-four (67%) patients received ICIs in the last 90 days of life and 117 (27%) patients received ICIs in the last 30 days of life. Patients who received ICIs in the last 30 days of life received fewer mean doses and more often =3 total doses. They also had higher mean Eastern Cooperative Oncology Group (ECOG) scores, more patients with ECOG =3, higher rates of dying in the hospital, and lower hospice enrollment. Patients treated with ICIs in the last 90 days of life received fewer doses, more often =3 total doses, had a higher mean ECOG score, more patients with ECOG =3, and lower hospice enrollment. $7.1 million USD was spent on ICI medications in the last 90 days of life.
Conclusion: ICI use near the end of life is associated with poor performance status, lower hospice enrollment, dying in the hospital, financial toxicity, and minimal clinical benefit.