Treatment preferences between survival and quality of life and their association with clinical outcomes in older adults with advanced cancer.
Authors: Daniel R. Richardson, Ying Wang, Marie Anne Flannery, Mostafa Refaat Mohamed, Allison Magnuson, Megan Wells, Rachael Tylock, Enrique Soto Pérez de Celis, Clark DuMontier, William Dale, Ronald M. Epstein, Judith O. Hopkins, Bryan A. Faller, Khalil Katato, Supriya Gupta Mohile, Kah Poh Loh
Journal: Journal of Clinical Oncology (2025)

11013 Background: Preference-concordant care improves quality of life (QoL) and reduces healthcare utilization. However, limited research exists on how preferences impact clinical outcomes in older adults with advanced cancer. Our study explores differences in outcomes between patients (pts) prioritizing extending survival versus maintaining QoL. We hypothesized that patients prioritizing survival would live longer, while those prioritizing QoL would have fewer treatment-related toxicities and hospitalizations. Methods: We analyzed data from pts aged ≥ 70 with incurable solid tumors or lymphoma and ≥ 1 impaired geriatric assessment domain starting a new systemic cancer treatment within NCI's Community Oncology Research Program as part of a cluster randomized trial (NCT02054741, PI: Mohile). Pts reported their preference for prioritizing extending survival versus maintaining QoL at baseline: agree, neutral, disagree. We used generalized linear mixed models and generalized estimating equations to assess the association of treatment preference with hospitalization and treatment-related toxicities, and Cox shared frailty models for survival. Analyses were adjusted for study arm, age, sex, race, education, and practice. Results: We included 706 pts. Mean age was 77.2 years (SD 5.4, range 70-96); 43% were female; and 89% were non-Hispanic white. Gastrointestinal (34.6%), lung (24.8%), and genitourinary (15.4%) cancers were most common. Fewer pts preferred to prioritize extending survival (n = 59, 8.4%) versus maintaining QoL (n = 506, 71.7%) versus no preference/neutral (n = 141, 20.0%). Choice of initial therapy (single agent, multiple agent, or combined chemotherapy plus another agent) did not differ by preference. Most pts (61.7%) had grade 3-5 treatment-related toxicity; 25.2% were hospitalized in the first 3 months; 26.3% died within 6 months; 47.3% died within one year. No significant associations were found between preference for prioritizing survival v. QoL and grade 3-5 toxicity (Risk ratio [RR] 0.90, 95% Confidence Interval [CI] 0.70–1.16), hospitalization (RR 0.81, 95% CI 0.48–1.36), nor survival (Hazard ratio 0.75, 95% CI 0.42–1.33 at 6 months; 1.18, 95% CI 0.82–1.71 at 1 year). Conclusions: Over two-thirds of older adults with advanced cancer prioritize maintaining QoL over extending survival. Prioritizing QoL was not associated with shorter survival. However, it was also not associated with reductions in hospitalization nor treatment-related toxicities. While these findings may suggest a lack of responsiveness of the healthcare system to patient preferences, additional studies are necessary to better evaluate this relationship. More research is needed to develop treatment modifications and interventions so that older adults with advanced cancer achieve those outcomes that matter most to them. Funding: UG1CA189961, R01CA177592.