Patients with metastatic cancer are more likely to receive immunotherapy at the end-of-life if treated at a nonacademic or low-volume cancer center compared to those treated at a high-volume or academic cancer center, highlighting the importance of experience in the appropriate use of immunotherapy.

In a retrospective study that assessed whether initiation of immunotherapy at the end of life is more common since the adoption of immune checkpoint inhibitors in clinical practice,¹ a key takeaway cited by sources was the answer to a secondary aim of the study, which looked at the use of immunotherapy in this setting by facility type.

“Experience with immunotherapy medications matters for patient outcomes,” says the lead author of the study, Daniel Kerekes, MD, general surgery resident at Yale University. Reasons for this may include improved patient selection or management of treatment-related side effects, more specialized resources or protocols in place to support patients receiving immunotherapy, or more personnel in all specialties familiar with the unique issues associated with immunotherapy, he adds.

The study of more than 240,000 patients with metastatic cancer (stage IV melanoma, stage IV non–small cell lung cancer, or stage IV kidney cancer) found that the odds of dying within 1 month of immunotherapy initiation were 31% lower in patients treated at an academic center versus a nonacademic center and 30% lower in patients treated at a high-volume center versus a low-volume center (p < .001 for both comparisons).

Overall, the study found increased use of immunotherapy at the end of life, with 1 in 14 immunotherapy centers initiating treatment within 1 month of death. Patients with metastatic disease that had spread to three or more organs were 3.8-fold more likely to die within 1 month of immunotherapy initiation than patients with only lymph node involvement.

For Michael Hoerger, PhD, author of the accompanying editorial to the study,² the study is a reminder that evidence-based practices are slow to be implemented, particularly at lower volume and in nonacademic centers. Academic and high-volume centers use immunotherapy more frequently early in the disease when it matters most, whereas low-volume and nonacademic centers often implement it too late for optimal effectiveness, such as the end of life, he says.

“The cancer center matters,” he says, adding the need for policies to accelerate dissemination of evidence-based practices. “In the meantime, high-volume academic centers are often the more appealing places to seek care and work.”

Saying that immunotherapy has revolutionized cancer treatment for many patients, Dr Kerekes underscores the need for broader education about best practices.

“Our findings emphasize the importance of regular tumor boards in which clinicians and facilities that prescribe less immunotherapy can conference with those who prescribe more immunotherapy about the most appropriate treatment for complex patients,” he says.

与在高容量或学术癌症中心接受治疗的转移性癌症患者相比，如果在非学术性或低容量癌症中心接受治疗，转移性癌症患者在临终时更有可能接受免疫治疗，这凸显了适当的经验的重要性。使用免疫疗法。

在一项回顾性研究中，评估了自临床实践中采用免疫检查点抑制剂以来在生命末期开始免疫治疗是否更为常见，¹消息来源引用的一个关键结论是该研究的次要目标的答案，该目标着眼于在这种情况下按设施类型使用免疫疗法。

该研究的主要作者、耶鲁大学普通外科住院医师 Daniel Kerekes 医学博士说：“免疫治疗药物的经验对患者的治疗效果很重要。”他补充说，其原因可能包括改善患者选择或治疗相关副作用的管理、支持接受免疫治疗的患者的更专业的资源或方案，或者所有专业领域有更多人员熟悉与免疫治疗相关的独特问题。

对超过 240,000 名转移性癌症（IV 期黑色素瘤、IV 期非小细胞肺癌或 IV 期肾癌）患者的研究发现，接受免疫治疗的患者在开始免疫治疗后 1 个月内死亡的几率降低了 31%学术中心与非学术中心相比，在高容量中心接受治疗的患者比在低容量中心接受治疗的患者要低 30%（两次比较的p < .001）。

总体而言，研究发现临终时免疫治疗的使用有所增加，四分之一的免疫治疗中心在死亡后 1 个月内开始治疗。患有已扩散到三个或更多器官的转移性疾病的患者在免疫治疗开始后 1 个月内死亡的可能性是仅淋巴结受累的患者的 3.8 倍。

对于该研究随附社论的作者 Michael Hoerger 博士来说，²该研究提醒人们，基于证据的实践实施缓慢，特别是在数量较少和非学术中心。他说，学术和大容量中心在疾病最重要的早期更频繁地使用免疫疗法，而小容量和非学术中心往往实施得太晚，无法获得最佳效果，例如生命的终结。

“癌症中心很重要，”他说，并补充说需要制定政策来加速基于证据的实践的传播。 “与此同时，人流量大的学术中心往往是寻求护理和工作更有吸引力的地方。”

Kerekes 博士表示，免疫疗法彻底改变了许多患者的癌症治疗，并强调需要进行更广泛的最佳实践教育。

他说：“我们的研究结果强调了定期肿瘤委员会的重要性，在该委员会中，开出较少免疫疗法的临床医生和机构可以与开出较多免疫疗法的人进行会议，讨论针对复杂患者的最合适的治疗方案。”