Impact of immune checkpoint inhibitor-based combination therapy on palliative care utilization for patients with metastatic renal cell carcinoma.
Authors: Baclig Nikita V. , Cabral Marsenne Y. , Kathuria-Prakash Nikhita , Velez Maria Antonia , Pantuck Allan J. , Drakaki Alexandra 
Published: June 2024

e24086

Background: Palliative care (PC) is a vital tool in the treatment of patients with metastatic cancer, yet its role in metastatic renal cell cancer (mRCC) is poorly defined. These individuals are increasingly treated with immune checkpoint inhibitor-based combination therapies (ICT). While this approach confers a survival advantage, it comes with additional toxicity that may necessitate PC. Yet, little is known about how ICT impacts PC use for mRCC patients. Here we present real-world data from a single center with an embedded PC provider that evaluates the effect of ICT on PC utilization in mRCC and identifies predictors of PC use for these patients in the modern treatment era. Methods: A retrospective sample of patients who received systemic treatment for mRCC at the Jonsson Comprehensive Cancer Center from 2013 to 2023 was studied. With institutional approval, the electronic health record was queried for patient and disease characteristics. PC referral, engagement, and number of visits were compared between patients who did and did not receive ICT as first-line treatment using Pearson’s chi-squared and two-sample T tests. Predictors of PC utilization were identified using multivariable logistic modeling. Results: 146 patients were included. Mean age at mRCC diagnosis was 62.6 (SD 13.1) and 69.2% were male. The diverse patient sample was 6.4% non-Hispanic Black, 16.4% Hispanic, and 11.4% Asian. The majority (78.8%) had clear cell pathology and 20.5% had sarcomatoid features. More than 50% had more than 3 metastatic sites. More patients received ICT (45.2%) than tyrosine kinase inhibitor monotherapy (39.0%) or other single agents (15.7%). Patients travelled 53.2 (SD 98.0) miles for clinic visits. Overall, 48.6% had a PC referral and 43.8% completed a visit. Of the 46.6% of patients who died, 64.7% had a PC referral and 60.3% had a PC visit. There were no statistically significant differences in PC referral (55% vs. 44%, p = 0.19), PC engagement (50% vs. 39%, p = 0.17), or PC visits (mean 4.6 vs. 3.1, p = 0.19) for patients who received ICT compared to other treatments. Controlling for other variables, statistically significant predictors of PC referral were number of metastatic sites (OR 1.57, p = 0.01), distance from clinic (OR 0.99, p = 0.04), and presence of sarcomatoid features (OR 2.85, p = 0.02). Statistically significant predictors of PC engagement included number of metastatic sites (OR 1.61, p = 0.01). Conclusions: Using single institution real-world data, we found that PC referrals and engagement were driven by disease burden and adverse pathology, but not by treatment regimen. Patients receiving first-line ICT did not demonstrate increased need for PC, while patients who lived farther from clinic were slightly less likely to receive a PC referral. Further study of the role and timing of PC in the modern mRCC treatment era are warranted.