In advanced stage cancer, the focus of treatment is prolonging life while preserving quality of life; a delicate balance to achieve when prescribing systemic anticancer therapy (SACT). Immunotherapeutic agents are becoming a larger part of oncological treatment approaches due to their efficacy and more favourable side effect profile over chemotherapy. Thirty-day mortality has been proposed as a measure of unsuccessful outcome.
In this retrospective audit of 300 patients, the 30-day mortality rate was assessed for patients receiving checkpoint inhibitors targeting CTLA-4 (ipilimumab), PD-1 (nivolumab, pembrolizumab) and PD-L1 (atezolizumab) for metastatic non-small cell lung cancer (NSCLC), renal cell carcinoma or melanoma.
The study included 172 patients with NSCLC, 112 with melanoma and 16 with renal cell carcinoma. The median age was 67 years and 86% were treated with palliative intent. Sixty-two of 300 (21%) patients died within 30 days of receiving therapy; 52 of these were secondary to disease progression, and four were potentially treatment related deaths. There was no significant difference in 30-day mortality dependent on age, gender, malignancy type or immunotherapy agent. Mean survival for all patients was 269 days.
Oncologists are challenged with prognosticating patients at diagnosis and during treatment; important to inform treatment decisions by clinicians, patients and families. The 30-day mortality rate of 21% is higher than other comparable studies that focus on SACT with chemotherapy, and implies that one in five patients received immunotherapy that conferred no benefit to survival or quality of life. The decision to continue or discontinue SACT should be made with consideration of the response to treatment, any treatment toxicity and the patient’s performance status, and should be reviewed prior to each treatment cycle.