End-of-life (EOL) outcomes and healthcare utilization for patients with hepatocellular carcinoma (HCC) who received immune checkpoint inhibition (ICI).
Authors: Wheless Margaret , Uhelski Anna-Carson Rimer , Cimino Sarah , Domenico Henry , Martin Sara F. , Karlekar Mohana , Heumann Thatcher , Ciombor Kristen Keon , Goff Laura Williams , Agarwal Rajiv 
Published: January 2025

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Background:
ICI is standard of care treatment for advanced HCC. EOL outcomes for patients with HCC who receive ICI prior to death are unknown. We examine relationships between EOL outcomes, healthcare utilization, and receipt of ICI for patients with advanced HCC referred to our tertiary center.
Methods:
Patients with advanced HCC evaluated at our center on or after January 1, 2020 and who died by March 29, 2024 were included. Patients were identified using diagnostic codes for liver cancer and HCC, and subsequently verified by manual review of the electronic health record. Demographic data, Child-Pugh (CP) status, and treatment history were collected. Primary EOL outcomes include: documentation of advance directives and goals of care (GOC) conversations, location of death, palliative care referral, hospice referral, days in hospice, and code status. Secondary healthcare utilization outcomes include: systemic therapy receipt, emergency department (ED) visits, hospitalization, and intensive care unit (ICU) admissions within 14, 30, and 90 days of death. Outcomes were stratified by ICI or non-ICI as last therapy received and p-values were derived using Pearson’s chi-square test for equality of proportions.
Results:
Of 221 evaluated patients, 71 died and met criteria for analysis. Baseline characteristics include mean age 64.1 years, 70.8% male, 71.8% received systemic treatment (median 1 line, range [1-7]), 54.1% CPA, 37.5% CPB, and 8.3% CPC at the time of last treatment. No statistically significant differences in primary EOL outcomes were detected when stratified by receipt of ICI or non-ICI as last therapy. Median days enrolled in hospice were not statistically significant between groups (24.5 days [non-ICI] vs 10 days [ICI]; p = 0.39). A higher proportion of patients who received ICI as last therapy had increased healthcare utilization across all outcomes (see Table).
Conclusions:
Patients with advanced HCC receiving ICI as their last treatment before death compared to those receiving non-ICI had similar EOL outcomes but higher healthcare utilization. This may be due to increased real-world use of ICI in CPB patients. Further investigation into risk stratification to predict high healthcare utilizers could guide decision-making and conversations around ongoing use of ICI, particularly near the EOL.

Healthcare utilization outcomes stratified by receipt of ICI.

Outcome Before Death
n
= 71

90 days
30 days
14 days

Therapy within Total: Last therapy ICI
33/71 (46.5%)69.7%
18/71 (25.4%)66.7%
6/71 (8.5%)33.3%

ED visit Total: Last therapy ICI
29/71 (40.8%)58.6%
27/71 (38.0%)55.6%
22/71 (30.1%)59.1%

Hospitalization Total: Last therapy ICI
32/71 (45.1%)59.4%
30/71 (42.3%)56.6%
29/71 (40.8%)58.6%

ICU admission Total: Last therapy ICI
6/71 (8.5%)66.7%
6/71 (8.5%)66.7%
6/71 (8.5%)66.7%