10 June 2024

Systemic Anticancer Therapy and Overall Survival in Patients with Very Advanced Solid Tumors

(JAMA Oncol, IF: 28.4)

  • Canavan ME, Wang X, Ascha MS, et al: Systemic Anticancer Therapy and Overall Survival in Patients With Very Advanced Solid Tumors. JAMA Oncol e241129, 2024

Importance 重要性

Two prominent organizations, the American Society of Clinical Oncology and the National Quality Forum (NQF), have developed a cancer quality metric aimed at reducing systemic anticancer therapy administration at the end of life. This metric, NQF 0210 (patients receiving chemotherapy in the last 14 days of life), has been critiqued for focusing only on care for decedents and not including the broader population of patients who may benefit from treatment.

两个著名的组织,美国临床肿瘤学会(ASCO)和国家质量论坛(NQF),已经开发了一个癌症质量指标,旨在减少生命结束时的系统性抗癌治疗用药。这个指标,NQF 0210(在生命的最后14天接受化疗的患者),因为只关注死者的治疗而受到批评,而不包括可能受益于治疗的更广泛的患者群体。


Objective 目的

To evaluate whether the overall population of patients with metastatic cancer receiving care at practices with higher rates of oncologic therapy for very advanced disease experience longer survival.



Design, setting, and participants 设计,设置和参与者

This nationwide population-based cohort study used Flatiron Health, a deidentified electronic health record database of patients diagnosed with metastatic or advanced disease, to identify adult patients (aged ≥18 years) with 1 of 6 common cancers (breast cancer, colorectal cancer, non-small cell lung cancer [NSCLC], pancreatic cancer, renal cell carcinoma, and urothelial cancer) treated at health care practices from 2015 to 2019. Practices were stratified into quintiles based on retrospectively measured rates of NQF 0210, and overall survival was compared by disease type among all patients treated in each practice quintile from time of metastatic diagnosis using multivariable Cox proportional hazard models with a Bonferroni correction for multiple comparisons. Data were analyzed from July 2021 to July 2023.

这项全国范围的基于人群的队列研究使用Flatiron Health,确诊转移性或晚期疾病患者的一个电子健康记录数据库,以识别确诊6种常见癌症中的1种(乳腺癌,大肠癌,非小细胞肺癌[ NSCLC ] ,胰腺癌,肾细胞癌和尿路上皮癌)的成年患者(年龄≥18岁),且2015年至2019年在医疗机构中接受治疗。根据回顾性分析的 NQF 0210比率,将实践分为五分位数,并使用多变量 Cox 比例风险模型,从转移性诊断开始,按照每个实践五分位数治疗的所有患者的疾病类型比较总生存Bonferroni校正,进行多重比较。数据分析自2021年7月至2023年7月。


Exposure 暴露

Practice-level NQF 0210 quintiles.

实践级别的 NQF 0210五分位数。


Main outcome and measure 主要结果和措施

Overall survival.



Results 结果

Of 78 446 patients (mean [SD] age, 67.3 [11.1] years; 52.2% female) across 144 practices, the most common cancer types were NSCLC (34 201 patients [43.6%]) and colorectal cancer (15 804 patients [20.1%]). Practice-level NQF 0210 rates varied from 10.9% (quintile 1) to 32.3% (quintile 5) for NSCLC and 6.8% (quintile 1) to 28.4% (quintile 5) for colorectal cancer. No statistically significant differences in survival were observed between patients treated at the highest and the lowest NQF 0210 quintiles. Compared with patients seen at practices in the lowest NQF 0210 quintiles, the hazard ratio for death among patients seen at the highest quintiles varied from 0.74 (95% CI, 0.55-0.99) for those with renal cell carcinoma to 1.41 (95% CI, 0.98-2.02) for those with urothelial cancer. These differences were not statistically significant after applying the Bonferroni-adjusted critical P = .008.

在144次实践中,78446名患者(平均年龄67.3[11.1]岁,女性52.2%)中,最常见的癌症类型是非小细胞肺癌(34201名患者[43.6% ])和大肠癌癌(15804名患者[20.1% ])。实践水平的 NQF 0210率从非小细胞肺癌的10.9% (五分位数1)至32.3% (五分位数5)不等,大肠癌为6.8% (五分位数1)至28.4% (五分位数5)。在最高和最低 NQF 0210五分位数治疗的患者之间没有观察到存活率的统计学显著差异。与在最低 NQF 0210五分位数实践中观察到的患者相比,在最高五分位数患者中观察到的死亡风险比从0.74(95% CI,0.55-0.99)到1.41(95% CI,0.98-2.02)对于那些患有尿路上皮癌的患者。应用 Bonferroni 调整后的临界 P = .008后,这些差异无统计学意义。


Conclusions and relevance 结论和相关性

In this cohort study, patients with metastatic or advanced cancer treated at practices with higher NQF 0210 rates did not have improved survival. Future efforts should focus on helping oncologists identify when additional therapy is futile, developing goals of care communication skills, and aligning payment incentives with improved end-of-life care.

在这项队列研究中,转移性或晚期癌症患者在 NQF 0210比率较高的实践中没有改善生存率。未来的努力应该集中在帮助肿瘤学家确定何时额外的治疗是徒劳的,发展医疗沟通技能的目标,并调整支付激励措施以改善临终治疗。