INTRODUCTION
Chemotherapy near end-of-life (EOL) may not prolong survival and can cause unnecessary suffering.1 While recent research has elucidated disparities in receipt of such futile care at EOL among Black and White patients, little is known about EOL disparities among other groups.2 Using chemotherapy receipt within 30 days of death as an indicator, we examined disparities in futile treatment near EOL for disaggregated race/ethnicity groups with non-small cell lung cancer (NSCLC).
METHODS
Using National Cancer Database (NCDB) data, we conducted a retrospective analysis of adult patients diagnosed with NSCLC (2004–2021) who died within 30 days of diagnosis as a proxy for EOL, and with known chemotherapy receipt status (defined binarily).
Using StataMP 18, we calculated adjusted odds ratios and 95% confidence intervals of receiving chemotherapy across racial/ethnic groups using a logistic regression model (Table 1, alpha < 0.05). The regression included a year*race interaction term to examine changes in futile chemotherapy receipt over time by race (alpha < 0.1).
Table 1.
a. Descriptive Statistics for Patients with Non-small Cell Lung Cancer who Died within 30 Days of Diagnosis. We Analyzed the Distributions of Year of Diagnosis, Race, Sex, Age, Insurance Status, Median Income Quartiles (2012–2016), Median Income Quartiles (2012–2016), Facility Type, Percent no High School Degree Quartiles (2012–2016), and CDCC Score
| Covariate | Frequency (Percent) | Odds ratio | 95% CI (Low) | 95% CI (High) | P-Value |
|---|---|---|---|---|---|
| Year of Diagnosis | |||||
| 2004–2012 | 66,777 (56.09%) | Reference Group | |||
| 2013–2021 | 52,269 (43.91%) | 0.6481844 | 0.6159876 | 0.682064 | <0.001 |
| Race | |||||
| White | 102,130 (85.79%) | Reference Group | |||
| Black | 12,874 (10.81%) | 0.7711968 | 0.6968462 | 0.8534803 | <0.001 |
| Southeast Asian | 617 (0.52%) | 0.5912312 | 0.3609767 | 0.968357 | 0.037 |
| East Asian | 853 (0.72%) | 1.417838 | 1.038607 | 1.935539 | 0.028 |
| South Asian | 175 (0.15%) | 1.526298 | 0.7805012 | 2.984731 | 0.217 |
| Indigenous | 349 (0.29%) | 0.8826532 | 0.5088316 | 1.531109 | 0.657 |
| Pacific Islander | 158 (0.13%) | 0.769688 | 0.3079672 | 1.923646 | 0.575 |
| Other | 1890 (1.59%) | 0.9556306 | 0.7537277 | 1.211618 | 0.708 |
| Year of Diagnosis*Race | |||||
| 2013–2021*Black | - | 1.048912 | 0.8910661 | 1.234719 | 0.566 |
| 2013–2021*Southeast Asian | - | 1.950384 | 0.987056 | 3.853882 | 0.055 |
| 2013–2021*East Asian | - | 0.886766 | 0.52307 | 1.503344 | 0.655 |
| 2013–2021*South Asian | - | 0.8930338 | 0.3196738 | 2.49476 | 0.829 |
| 2013–2021*Indigenous | - | 0.8257849 | 0.3355816 | 2.032056 | 0.677 |
| 2013–2021*Pacific Islander | - | 0.2372031 | 0.0269528 | 2.087552 | 0.195 |
| 2013–2021*Other | - | 0.9497646 | 0.6504454 | 1.386823 | 0.79 |
| Sex | |||||
| Male | 70,224 (58.99%) | Reference Group | |||
| Female | 48,822 (41.01%) | 0.8963773 | 0.8554933 | 0.9392151 | <0.001 |
| Age | |||||
| 18–64 | 30,335 (25.48%) | Reference Group | |||
| 65–74 | 37,190 (31.24%) | 0.7278057 | 0.6819684 | 0.7767238 | <0.001 |
| 75–79 | 20,623 (17.32%) | 0.5388897 | 0.4974558 | 0.5837747 | <0.001 |
| 80+ | 30,898 (25.95%) | 0.2725058 | 0.2502503 | 0.2967404 | <0.001 |
| Insurance Status | |||||
| Not Insured | 4973 (4.18%) | Reference Group | |||
| Private Insurance | 21,041 (17.67%) | 1.333173 | 1.196192 | 1.485841 | <0.001 |
| Medicaid | 7248 (6.09%) | 0.9398208 | 0.8243014 | 1.071529 | 0.354 |
| Medicare | 81,716 (68.64%) | 1.052618 | 0.9404349 | 1.178183 | 0.372 |
| Other Government | 1619 (1.36%) | 0.8008956 | 0.6346842 | 1.010635 | 0.061 |
| Insurance Status Unknown | 2449 (2.06%) | 0.9845522 | 0.8181819 | 1.184752 | 0.869 |
| Median Income Quartiles (2012–2016) | |||||
| < $40,227 | 28,050 (23.56%) | Reference Group | |||
| $40,227-$50,353 | 30,134 (25.31%) | 1.05663 | 0.9841304 | 1.134471 | 0.129 |
| $50,354-$63,332 | 27,695 (23.26%) | 1.10464 | 1.0227 | 1.193146 | 0.011 |
| > = $63,333 | 33,167 (27.86%) | 1.179805 | 1.083269 | 1.284944 | <0.001 |
| Facility Type | |||||
| Community Cancer Program | 11,607 (9.75%) | Reference Group | |||
| Comprehensive Community Cancer Program | 53,996 (45.36%) | 1.16236 | 1.071004 | 1.261509 | <0.001 |
| Academic/Research Program (includes NCI-designated comprehensive cancer centers) | 27,990 (23.51%) | 0.9633653 | 0.8808646 | 1.053593 | 0.414 |
| Integrated Network Cancer Program | 25,453 (21.38%) | 1.03641 | 0.9470069 | 1.134252 | 0.437 |
| Percent No High School Degree Quartiles (2012–2016) | |||||
| > = 17.6% | 28,152 (23.65%) | Reference Group | |||
| 10.9–17.5% | 35,349 (29.69%) | 1.047909 | 0.9799002 | 1.120637 | 0.172 |
| 6.3–10.8% | 32,935 (27.67%) | 1.04271 | 0.9658591 | 1.125675 | 0.284 |
| < 6.3% | 22,610 (18.99%) | 1.118769 | 1.022057 | 1.224633 | 0.015 |
| CDCC Score | |||||
| 0 | 56,918 (47.81%) | Reference Group | |||
| 1 | 35,119 (29.5%) | 0.9385472 | 0.890922 | 0.9887183 | 0.017 |
| 2 | 16,550 (13.9%) | 0.82915 | 0.7712296 | 0.8914204 | <0.001 |
| > = 3 | 10,459 (8.79%) | 0.6505406 | 0.5894587 | 0.7179519 | <0.001 |
We categorized patients into bins for age (18–64, 65–74, 75–79, and 80 + years old), diagnosis year (2004–2008, 2009–2013, 2014–2018, 2019–2021), and race/ethnicity (White, Black, Southeast Asian, East Asian, South Asian, Pacific Islander, and Other)
RESULTS
119,046 individuals died within 30d of diagnosis. Of these, 85.9% identified as White (n = 102,130), 10.81% as Black (n = 12,874), 0.52% as Southeast Asian (n = 617), 0.72% as East Asian (n = 853), 0.15% as South Asian (n = 175), 0.29% as American Indian, Aleutian, or Eskimo (n = 349), 0.13% as Pacific Islander (n = 158) and 1.59% as Other (n = 1,890). 56.09% of patients were diagnosed between 2004–2012 (n = 66,777) and 43.91% between 2013–2021 (n = 52,269).
Chemotherapy was administered for 7.1% of White patients, 5.7% of Black patients, 5.8% of Southeast Asian patients, 8.1% of East Asian patients, 9.7% of South Asian patients, 6.3% of American Indian, Aleutian, or Eskimo patients, 3.8% of Pacific Islander patients, and 6.6% of patients of other racial/ethnic groups (Fig. 1). East Asian patients were 1.42 × more likely (P = 0.028), Black patients were 0.77 × as likely (P < 0.001), and Southeast Asian patients were 0.59 × as likely (P = 0.037) to receive chemotherapy compared to White patients (Table 1).
Figure 1.
Rate of chemotherapy receipt by racial/ethnic group for patients with NSCLC who died within 30 days of diagnosis, stratified by year of diagnosis
Of Southeast Asian patients diagnosed between 2013–2021 who died within 30 days of diagnosis, 6.3% received chemotherapy, compared with 5.4% among those diagnosed from 2004-2012, compared with a nominal decrease over time for all other groups, suggesting a significant increase in futile chemotherapy receipt for Southeast Asian patients (Table 1). The year*race term was significant for Southeast Asian patients, suggesting that the improvement (lower rate) of futile chemotherapy over time was not equitably distributed (95%, Pinteraction = 0.055, compared with decreases for the reference group).
The rate of receipt of futile chemotherapy has decreased in recent years. Older patients, female patients, patients with non-insurance, patients with greater comorbidity, and patients in ZIP codes with lower socioeconomic status were less likely to undergo futile chemotherapy.
DISCUSSION
We found increased odds of chemotherapy receipt at EOL for Southeast Asian patients in more recent years, suggesting trends of burdensome treatment for this population. Greater odds of aggressive EOL treatment for Southeast Asian patients is concerning considering the importance of pain minimization and symptom management as the primary palliative care priorities among many AA subgroups.3 While Southeast Asian subgroups remain comparatively understudied, many AAs are less likely to be enrolled in hospice care and more likely to die in the hospital.4,5
Our findings highlight the need to facilitate values-concordant, QOL-maximizing EOL care for diverse patients. Raising awareness about EOL care options instead of aggressive treatments can address misconceptions and stigma surrounding palliative care in diverse sociocultural communities.
Declarations
Conflicts of Interest
P.I. and E.C.D. are funded in part through the Prostate Cancer Foundation and through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748). P.I. received research grants from Incyte (to the institution) and has participated in the Advisory Board of AstraZeneca, Novocure, Johnson and Johnson, BioConvergent Health, Pfizer, and NGM Biosciences. All other authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Khushi Kohli and Stephanie Wang contributed equally.
References
- 1.Harrington SE, Smith TJ. The Role of Chemotherapy at the End of Life. JAMA J Am Med Assoc. 2008;299(22):2667-2678. 10.1001/jama.299.22.2667 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Canavan M, Wang X, Ascha M, et al. End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting. J Clin Oncol. 2023;41(30):4729-4738. 10.1200/JCO.22.02180 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.La IS, Lee MC, Hinderer KA, et al. Palliative Care for the Asian American Adult Population: A Scoping Review. Am J Hosp Palliat Med. 2021;38(6):658-670. 10.1177/1049909120928063 [DOI] [PubMed] [Google Scholar]
- 4.Ngo-Metzger Q, Massagli MP, Clarridge BR, et al. Linguistic and Cultural Barriers to Care. J Gen Intern Med. 2003;18(1):44-52. 10.1046/j.1525-1497.2003.20205.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kohli K, Kohli M, Jain B, et al. Characterizing disparities in receipt of palliative care for Asian Americans, Native Hawaiians, and Pacific Islanders with metastatic cancer in the United States. Support Care Cancer. 2024;32(8):494. 10.1007/s00520-024-08633-w [DOI] [PubMed] [Google Scholar]