Prognostic Risk Stratification and End-of-Life Care Outcomes in Patients With Metastatic Melanoma Treated With Immune Checkpoint Inhibitors

Author:

Grad Robert N1,Jung Seungyeon2,Ye Fei3,Sun Lili3,Johnson Douglas B1,Agarwal Rajiv1ORCID

Affiliation:

1. Department of Medicine, Vanderbilt University Medical Center , Nashville, TN , USA

2. Department of Medicine, Vanderbilt University School of Medicine , Nashville, TN , USA

3. Department of Biostatistics, Vanderbilt University Medical Center , Nashville, TN , USA

Abstract

Abstract Introduction 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. Materials and Methods 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. Results 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. Conclusion 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.

Funder

National Institutes of Health

National Cancer Institute

Publisher

Oxford University Press (OUP)

Subject

Cancer Research,Oncology

Reference24 articles.

1. Cancer statistics, 2021;Siegel,2021

2. Meta-analysis of phase II cooperative group trials in metastatic stage IV melanoma to determine ­progression-free and overall survival benchmarks for future phase II trials;Korn,2008

3. Current state of melanoma diagnosis and treatment;Davis,2019

4. Immune checkpoint inhibitors in melanoma;Carlino,2021

5. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma;Larkin,2015

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