癌症老年患者临近死亡时化疗和靶向治疗使用的增减趋势。
Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer.
机构信息
1 The University of Texas MD Anderson Cancer Center, Houston, TX.
2 University of Michigan, Ann Arbor, MI.
出版信息
J Clin Oncol. 2019 Jul 10;37(20):1721-1731. doi: 10.1200/JCO.18.02067. Epub 2019 May 29.
PURPOSE
End-of-life (EOL) chemotherapy has been described as the most widespread, wasteful, and unnecessary practice in oncology, with benchmarking aimed to reduce physician use of chemotherapy within 14 days of EOL. We evaluated the recent transformation of EOL chemotherapy and targeted therapy practices nationally.
METHODS
In patients older than 65 years of age who died as a result of breast (n = 19,887), lung (n = 79,613), colorectal (n = 29,844), or prostate (n = 17,910) cancer between 2007 and 2013, we evaluated the guideline-benchmarked measure of chemotherapy use within 14 days of EOL in SEER-Medicare. Comparison outcomes were nonbenchmarked measures of chemotherapy and targeted therapy across time points within 6 months of EOL. Cochran-Armitage test was used to evaluate temporal trends. Multilevel logistic models and intraclass correlation coefficient was used to evaluate variation in EOL chemotherapy use at the physician level.
RESULTS
From 2007 to 2013, chemotherapy within 14 days of EOL declined from 6.7% to 4.9% of patients ( < .001; ∆ = -1.8%). Similar declines occurred for chemotherapy within 1 month ( < .001; ∆ = -1.8%) and 2 months ( < .001; ∆ = -1.3%) of EOL. In contrast, chemotherapy within 4 to 6 months of EOL rose ( ≤ .04; ∆ = 0.7% to 1.7%), and 43.0% of all patients received chemotherapy within 6 months of EOL. Frequency of targeted therapy use across all time points within 6 months of EOL was stable to marginally rising from 2007 to 2013 ( = .09 to .82; ∆ = -0.2% to 1.8%); overall, 1.2% received targeted therapy within 14 days and 3.6% within 1 month of EOL. By 2013, 13.2% of patients received any targeted therapy within 6 months of EOL. In a multilevel model, 5.19% (intraclass correlation coefficient) of variation in 14-day EOL chemotherapy was attributed to the physician level.
CONCLUSION
With national benchmarking, chemotherapy within 14 days of EOL successfully declined to less than 5%, with comprehensive benchmark uptake by physicians. Results may inform current strategies to help to achieve high-value EOL oncology practice.
目的
终末期（EOL）化疗被描述为肿瘤学中最广泛、最浪费和最不必要的实践，基准测试旨在减少医生在 EOL 后 14 天内使用化疗。我们评估了全国范围内 EOL 化疗和靶向治疗实践的最新转变。
方法
在 2007 年至 2013 年间，65 岁以上死于乳腺癌（n=19887）、肺癌（n=79613）、结直肠癌（n=29844）或前列腺癌（n=17910）的患者中，我们评估了 SEER-Medicare 中 EOL 后 14 天内使用化疗的指南基准衡量标准。比较结果是 EOL 后 6 个月内不同时间点非基准衡量的化疗和靶向治疗。采用 Cochran-Armitage 检验评估时间趋势。采用多水平逻辑模型和组内相关系数评估医生水平 EOL 化疗使用的变异性。
结果
2007 年至 2013 年间，EOL 后 14 天内的化疗从 6.7%降至 4.9%（<0.001；∆=-1.8%）。EOL 后 1 个月（<0.001；∆=-1.8%）和 2 个月（<0.001；∆=-1.3%）的化疗也出现类似下降。相比之下，EOL 后 4 至 6 个月的化疗增加（≤0.04；∆=0.7%至 1.7%），43.0%的患者在 EOL 后 6 个月内接受化疗。EOL 后 6 个月内所有时间点的靶向治疗使用频率稳定至略有上升，从 2007 年至 2013 年（=0.09 至 0.82；∆=-0.2%至 1.8%）；总体而言，1.2%的患者在 EOL 后 14 天内接受靶向治疗，3.6%的患者在 EOL 后 1 个月内接受靶向治疗。到 2013 年，13.2%的患者在 EOL 后 6 个月内接受任何靶向治疗。在多水平模型中，14 天 EOL 化疗的 5.19%（组内相关系数）归因于医生水平。
结论
通过全国性基准测试，EOL 后 14 天内的化疗成功降至 5%以下，医生全面采用基准测试。结果可能为当前实现高价值 EOL 肿瘤学实践的策略提供信息。
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