Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
Oncologist. 2023 Oct 3;28(10):911-916. doi: 10.1093/oncolo/oyad219.
The emergence of immune checkpoint inhibitors (ICIs) has improved survival outcomes in patients with metastatic melanoma, while potentially increasing the use of systemic therapy near the end of life (EOL). Yet, less is known on how to facilitate treatment decision making and identify patients who might benefit from early palliative care comanagement.
We determined baseline clinical and laboratory factors that are associated with poor prognosis for patients with advanced melanoma treated with ICIs. We subsequently identified prognostic subgroups to evaluate association with EOL outcomes and determine if EOL care varied across prognostic strata.
Our cohort included 398 patients with metastatic melanoma treated with ICIs. Factors associated with overall survival (OS) included: lactate dehydrogenase, neutrophil/lymphocyte ratio, performance status, prior therapies, liver metastases, and lung metastases. Patients were stratified by risk of death using risk scores developed from multivariable analyses. A total of 205 patients died: 45/133 (34%) low-risk, 63/133 (47%) medium-risk, and 97/132 (73%) of high-risk patients. Among those who died, higher risk patients were more likely to receive ICIs within 14, 30, and 90 days of death. We found no association between risk group and hospice referrals or location of death.
Patients with metastatic melanoma at highest risk of death as defined by our model were more likely than lower-risk patients to receive ICIs near the EOL. Prognostic risk stratification may guide early palliative care interventions to appropriately utilize ICIs and optimize EOL care.
免疫检查点抑制剂 (ICI) 的出现改善了转移性黑色素瘤患者的生存结果，同时可能增加了生命末期 (EOL) 时的全身治疗使用。然而，对于如何促进治疗决策制定以及确定可能从早期姑息治疗联合管理中受益的患者，了解较少。
我们确定了与接受 ICI 治疗的晚期黑色素瘤患者预后不良相关的基线临床和实验室因素。随后，我们确定了预后亚组，以评估与 EOL 结局的关联，并确定 EOL 护理是否在不同的预后分层中有所不同。
我们的队列包括 398 名接受 ICI 治疗的转移性黑色素瘤患者。与总生存期 (OS) 相关的因素包括：乳酸脱氢酶、中性粒细胞/淋巴细胞比值、表现状态、既往治疗、肝转移和肺转移。使用多变量分析开发的风险评分对患者进行死亡风险分层。共有 205 名患者死亡：133 名中的 45 名 (34%)为低危，133 名中的 63 名 (47%)为中危，132 名中的 97 名 (73%)为高危患者。在死亡患者中，高风险患者在死亡前 14、30 和 90 天内更有可能接受 ICI 治疗。我们没有发现风险组与临终关怀转介或死亡地点之间的关联。
根据我们的模型，死亡风险最高的转移性黑色素瘤患者比低危患者更有可能在 EOL 时接受 ICI 治疗。预后风险分层可能指导早期姑息治疗干预，以适当利用 ICI 并优化 EOL 护理。
