Metastatic cancer patients hospitalized at initial diagnosis: when does rescue systemic therapy make sense?

Purpose: Little is known about metastatic cancer patients who are hospitalized at diagnosis because of impaired performance status and/or severe symptoms: this study aims to explore their prognosis and the effect of systemic anti-neoplastic treatment (SANT) initiation on their outcome.

Methods: A prospective study of adult inpatients with a newly diagnosed metastatic solid tumor registered in seven cancer-facilities in France. During a three-month follow-up, socio-demographic characteristics, response rate and duration of response for patients receiving SANT, length of hospital stay and survival were collected. Correlation with clinical prognostic and predictive factors were analyzed. We also assessed access to palliative care and end-of-life care aggressiveness criteria within this patient population.

Results: 107 patients were included from November 2021 to April 2022. Seventy-four (69%) underwent SANT. Median overall survival was 1.7 months for the entire cohort. Forty (37%) were alive at 3 months, including 39 patients that started SANT and 1 patient that received BSC only. Factors associated with the initiation of a SANT were young age (OR=0,94 [0,90; 0,98]), low Charlson Comorbidity Index (OR=0,56 [0,42; 0,73]), SANT initiated at patient’s or caregiver’s request (OR=0,07 [0,02; 0,17] and 0,17 [0,06; 0,42], respectively). Patients with biomarker-based targeted therapy and hormone therapy had a better outcome (8 out of 10 patients alive). PALLIA-10 score superior to 5 was a significant predictive factor for mortality (HR=3,24; p<0,001). The majority of oncologists (60%) and patients (60%) shared concordant treatment objectives, primarily palliative, aiming to increase survival (65 patients) or improve quality of life (13 patients). However, 15 patients (40%) misperceived the treatment objective as curative, with only 3 of them aligning with the oncologist's perspective. A high prevalence of aggressiveness criteria for end-of-life care, including repeated emergency department admissions, late initiation or continuation of anticancer treatments, and late palliative care engagement, was observed in the ONIRIS patient population. Many patients encountered a specialized palliative care team very late in their illness trajectory (23% of deceased patients within the last three days of their lives).

Conclusion: Metastatic cancer patients hospitalized at the time of diagnosis share a similar poor survival and a high exposure to agrressiveness of care near the end of life. The initiation of SANT does not always impact their outcome. Larger prospective studies with longer follow-up are needed to better assess the effect of SANT in this population.