A Review of Chemotherapy and Radiotherapy near the End of Life in Individuals with Metastatic Non-small Cell Lung Cancer

Objectives: Appropriate chemotherapy and radiation near end of life is a moving target; challenged by increasing costs, evolving therapies, new reimbursement models and quality metrics. We review treatment trends and variables impacting the initiation of chemotherapy (CHT) and radiotherapy (XRT) in the final 60, 30 and 14 days of life in metastatic non-small cell lung cancer (NSCLC). Methods: The Florida Cancer Data System was studied to complete a retrospective cohort analysis of 48,858 individuals with Stage IV (M1) NSCLC from 1995-2010. We evaluated the initiation of CHT and XRT after diagnosis and associations with patient demographics, insurance and socioeconomic status (SES). Results: The use of CHT increased from 35% to 49%, while XRT decreased from 52% to 37% between 1995 and 2010. Initial courses of CHT occurred 8.1%, 5.0%, and 3.6% in the final 60, 30, and 14 days of life, and XRT 13.8%, 7.7%, and 5.2% of the time, respectively. Younger, married, and male patients were more likely to receive treatment. Low SES (OR 0.685, 95% CI 0.633-0.741) and uninsured individuals (OR 0.678, 95% CI 0.572-0.804) were less likely to receive CHT. SES and insurance did not impact XRT. Conclusions: The initiation of late CHT and XRT treatments decreased from 1995-2010. It persisted above 3% in the last 14 days of life. Clinicians may struggle to taper treatment before death, especially in patients with limited survival. It is important to recognize the complexities of death and dying and the potential influences of palliative care in affecting treatment decisions.