End-of-Life Care Patterns in Older Patients with Diffuse Large B-Cell Lymphoma (DLBCL) in the Real-World Setting

Introduction: DLBCL is an aggressive malignancy with over 50% of patients diagnosed above 65 years of age. Relapsed/refractory DLBCL is potentially curable; however, age is an adverse prognostic factor with many older adults (OA) succumbing to the disease. Patients and clinicians are faced with challenging decisions to initiate curative treatment while optimizing decisions for end-of-life care. Our study investigates end-of-life care patterns in OA with DLBCL treated in the real-world (rw) setting.

Methods: This retrospective, observational study utilized the COTA rw database derived from the electronic health records (EHRs) of partner healthcare centers in the United States. Eligible patients were aged ≥ 70 years (yrs) at diagnosis with DLBCL between 1/1/2017 and 12/31/2021. Patients were excluded from the study if they were missing or had imprecise (i.e., year-only) key study dates. Patient characteristics and treatment patterns were summarized descriptively by line of therapy (LOT) and subgroups. Hospice and palliative care referral were captured as documented in the EHR and combined into a single variable. Rw time to next treatment (rwTTNT) and overall survival (rwOS) were evaluated using the Kaplan-Meier method.

Results: A total of 1,920 patients met the study criteria. Median age at diagnosis was 77 (range: 70-90+) yrs, and patients were predominantly male (53.3%), White (69.6%), and treated in the community setting (87.1%). Patients' age groupings included 70-79 yrs (n=1163, 60.6%), 80-89 yrs (n=659, 34.3%) and 90+ yrs (n=98, 5.1%). Median follow up time from diagnosis was 25.2 (range: 0.1, 86.9) months (mos).

Of the 1,766 patients who received 1L, 329 (18.6% of 1L treated) went on to receive 2L, of which 131 (39.8% of 2L treated) and 60 (45.8% of 3L treated) went on to receive 3L and 4L, respectively. 88% of initial 1L regimens were considered curative in their intent. There were 154 (8.0%) patients who did not receive anti-lymphoma therapy, with a median follow up time from diagnosis of 2.5 mos (range: 0.1, 63.0) and median (95% CI) rwOS of 3.8 (2.8, 6.5) mos. Among patients who did not receive therapy, hospice referrals were documented for 41.6% of the population. In the study population, median rwTTNT (95% CI) from 1L, 2L, 3L, and 4L initiation was 43.7 (35.6, 49.8), 4.6 (4.1, 6.0), 4.0 (3.4, 5.3), and 5.0 (3.3, 8.0) mos, respectively. Median rwOS from 1L, 2L, 3L, and 4L initiation was 57.1 (52.2, 59.9), 12.4 (9.8, 15.1), 11.0 (8.0, 17.7), and 9.1 (5.1, 14.7) mos, respectively.

Among patients who were noted as deceased in the COTA database (N=858), median time from last therapy to death was 2.6 (0.9, 11.9) mos. The percent of patients receiving treatment within 0-30 and 31-60 days of death was 24.6% and 12.9%, respectively. A total of 272 (31.7%) patients had documentation of prior hospice or palliative care referral (8.1% had multiple referrals). The referral rate was greatest for patients 90+ yrs (38.0%). Median (IQR) time from hospice or palliative care referral to death was 0.7 (0.2, 1.9) mos. A total of 23 patients (8.5%) received additional systemic therapy on or after the date of hospice/palliative care referral.

Time from last LOT to hospice referral decreased by total LOTs received. Patients receiving only 1 LOT had the longest median time to referral (1.0 mos), followed by 2 LOTs (0.6 mos), 3 LOTs (0.4 mos), and 4 LOTs (0.1 mos). Interestingly, among patients who were referred to hospice and deceased, there was no difference in the time from last therapy to hospice referral based on age categories. The median (IQR) time from referral to death was 0.7 mos (0.2, 1.9); for patients 70-79 yrs, median 0.5 (0.2, 1.1) and 80-89 yrs, median 0.7 (0.3, 3.2), and those 90+ yrs median 1.4 (0.4, 2.1).

Conclusions: Our study found that only a minority of OA with DLBCL had documentation of hospice or palliative care referral, indicating a continued need for the optimization of end-of-life care and quality of life. There is ongoing need to understand the value of care delivered near the end of life in terms of both extending duration and quality of life, with the potential to help guide shared decision making with more accurate estimates of outcomes.