A new study exploring the use of immune checkpoint inhibitors at the end of life has found that use of these immunotherapy drugs is associated with poor performance status, lower hospice enrollment, increased odds of dying in the hospital, and increased financial toxicity — with minimal benefit to the patient.

“As a result of recent advances with immune checkpoint inhibitors (ICIs), some patients with advanced cancer who were previously not candidates for traditional chemotherapy are now receiving treatment with ICIs,” the researchers wrote. “This has led some oncologists to treat patients who are elderly, have poor performance status, and are close to the end of life.”

In this retrospective analysis, researchers wanted to evaluate how ICIs were used in end-of-life situations. The study looked at data from 441 patients treated with ICIs at the University of Iowa who died between August 2014 and December 2018. They compared characteristics and outcomes among patients who received ICIs in the last 90 days of life (67%) and in the last 30 days of life (27%).

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Patients treated with ICIs within 30 days of death were more likely to have fewer doses and often received 3 or fewer total doses. These patients also had a higher mean Eastern Cooperative Oncology Group (ECOG) score, including more patients with a score of 3 or greater (22% vs 7%). 

Additionally, patients who received ICIs within 30 days of death had a significantly lower rate of hospice enrollment (55% vs 81%; P <.001), and were more likely to die in the hospital (33% vs 19%; P =.002).

“The lack of response markers to ICI therapy continues to make treatment decisions challenging for oncologists and patients,” the researchers noted. “Our results demonstrate that in patients with solid tumors, poor performance status remains an important prognostic indicator and treating these patients with ICIs is contrary to the American Society of Clinical Oncology’s first of 5 key opportunities to improve care and reduce costs stating, ‘do not use cancer-directed therapy for patients with solid tumors who have the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and with no strong evidence supporting the clinical value of further anticancer treatment.’”

Editor’s note: This article was corrected to reflect that the researched compared characteristics and outcomes among patients who received ICIs in the last 90 days of life (67%) and in the last 30 days of life (27%), not patients 30 days or less from death and more than 30 days from death as was originally stated.


Glisch C, Saeidzadeh S, Snyders T, Gilbertson-White S, Hagiwara Y, Lyckholm L. Immune checkpoint inhibitor use near the end of life: a single-center retrospective study [published online November 8, 2019]. J Palliat Med. doi: 10.1089/jpm.2019.0383