The Last 30 Days – Wide Differences in Oncologists' End-of-Life Treatment Practices

As patients with cancer approach death, discontinuing further systemic cancer treatment may improve their quality of life . As the disease progresses, the balance of risks and benefits involved in deciding whether to continue treatment changes. This is particularly evident in older and frail patients, for whom the potential benefits of treatment diminish while side effects and risks carry greater weight. 

Treatments That Do More Harm Than Good at the End of Life

Clinical guidelines and quality improvement initiatives have aimed to reduce the overuse of chemotherapy that will not benefit patients near the end of life, identifying this as a key way to improve the quality and value of oncology care. However, the rapidly increasing availability and use of newer therapies at the end of life keep these concerns relevant, as clinical guidance on these treatments remains limited.

Decisions to discontinue treatment should be based on clinical findings and the patient's preferences. However, the wishes of both patients and their families, as well as oncologists' tendency to administer systemic treatment near the end of life, may strongly influence whether treatment continues.

A professor of health economics at Rutgers University in the United States, Dr. Ayşe Akıncıgil , and her colleagues conducted a study published on July 30, 2024, in Cancer . The study revealed substantial differences among oncologists in the administration of systemic cancer therapy during patients' last 30 days of life. In particular, patients under the care of oncologists with high prescribing rates were four and a half times more likely to receive systemic treatment .

Study Design

The researchers used the SEER-Medicare database, which contains information on patients who died of cancer between 2012 and 2017. The study included a total of 17,609 patients with breast, lung, colorectal, or prostate cancer treated by 960 oncologists. Patients were required to have at least one claim for systemic cancer therapy during their last 180 days of life. The treating oncologist was identified based on the treatment claim closest to death. The study used multilevel models to estimate oncologists' rates of providing cancer treatment at the end of life.

Key Findings

• Treatment Rates: Oncologists in the top 5 percent of the prescribing distribution administered treatment to 45% of their patients during the last 30 days of life, compared with 17% among oncologists in the bottom 5 percent.

• Likelihood of Receiving Treatment: Compared with patients treated by low-prescribing oncologists, those treated by high-prescribing oncologists were four times more likely to receive systemic therapy at the end of life (odds ratio [OR], 4.42; 95% confidence interval [CI], 4.00-4.89).

• Hospital Admissions: A large proportion of patients of high-prescribing oncologists were hospitalized near the end of life (58%), compared with 51.9% among patients of low-prescribing oncologists.

• Hospice Enrollment: A large proportion of patients of oncologists with high prescribing rates either did not enroll in hospice during the last 30 days of life or enrolled three days before death. These findings emphasize the importance of initiating hospice care in a timely manner to improve the quality of end-of-life care.

• Patient Characteristics: The likelihood of receiving systemic treatment during the last 30 days of life was also influenced by certain patient characteristics . For example,

  • A longer interval between diagnosis and death, a higher tumor grade (grade 3 or 4), non-African American ethnicity, being unmarried, and older age all made patients less likely to receive treatment.

  • Patients with breast cancer were also more likely to receive treatment during this period than patients with lung cancer.

Commentary

This study demonstrated wide differences in how oncologists administer cancer treatments during the last 30 days of life. In particular, patients under the care of oncologists with high prescribing rates were four and a half times more likely to receive systemic treatment. This illustrates how widely treatment decisions can vary during the final days of life and how strongly oncologists' personal tendencies may influence these decisions.

The study also emphasizes that factors such as oncologists' training, clinical skills, and personal values play an important role in treatment decisions. A better understanding of these differences could contribute to efforts to reduce the overuse of cancer treatment at the end of life. Future studies should aim to examine oncologists' personal characteristics and treatment approaches in greater detail to better manage these tendencies and improve patient outcomes.

Findings of this kind may help shape clinical guidelines and educational programs to support oncologists in making informed, patient-centered treatment decisions. In particular, identifying the most appropriate treatment options for patients and families near the end of life is a complex process that requires effective communication skills and empathy. Supporting oncologists through this process may therefore improve the quality of patient care and prevent unnecessarily intensive treatments at the end of life. This study points to the potential to improve quality and value in oncology and provides an important resource for future educational and policy developments.

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• Related topic: Let Us Work Together to Avoid Overtreatment That Can Lead to Death in Cancer!