Background: The treatment landscape for advanced solid malignancies has changed significantly since the advent of checkpoint inhibition immunotherapy. Compared to chemotherapy, immunotherapy offers a favourable toxicity profile and greater potential for durable responses. While mortality within 30 days of chemotherapy is recognised as an important quality assurance measure, data is limited regarding immunotherapy in this context.
Methods: A retrospective review of patients with advanced solid malignancies treated with immunotherapy within Cairns and Hinterland Hospital and Health Service between June 2015 and June 2019.
Results: 230 patients were treated with immunotherapy and 30 patients (13%) died within 30 days of treatment. Anti-PD-L1/PD-1 therapy was more common than anti-CTLA-4 or combination regimens (80% vs. 13% vs. 3%). Median age was 70 years (38–87). The most common malignancies were melanoma (50%) and lung cancer (37%). Most patients were pre-treated (80%). Poor prognostic features were common: ECOG 3–4 (33%), brain metastases (33%), ≥ 3 metastatic sites (53%) and raised LDH (80%). The median number of cycles was 2 (1–61) and 13 patients died within 30 days of first treatment (6%). Most patients died of progressive disease (84%) and there were no grade 3+ toxicities. 71% died in hospital and 36% received acute treatment within 48 hours of death. Only 18% died in a palliative care unit and 11% died at home. Resuscitation plans were documented in 50% at the time of final treatment. Discussion regarding very poor prognosis and/or treatment futility was documented in 52% of cases.
Conclusion: Thirty-day mortality rates after immunotherapy were in keeping with historically published data for chemotherapy. While there were no significant treatment related toxicities, at least a quarter of patients received acute medical care within 48 hours of death. Reassuringly, most patients had clearly participated with advanced care planning and were involved with palliative care.