ImportanceTwo prominent organizations, the American Society of Clinical Oncology and the National Quality Forum (NQF), have developed a cancer quality metric aimed at reducing systemic anticancer therapy administration at the end of life. This metric, NQF 0210 (patients receiving chemotherapy in the last 14 days of life), has been critiqued for focusing only on care for decedents and not including the broader population of patients who may benefit from treatment.ObjectiveTo evaluate whether the overall population of patients with metastatic cancer receiving care at practices with higher rates of oncologic therapy for very advanced disease experience longer survival.Design, Setting, and ParticipantsThis nationwide population-based cohort study used Flatiron Health, a deidentified electronic health record database of patients diagnosed with metastatic or advanced disease, to identify adult patients (aged ≥18 years) with 1 of 6 common cancers (breast cancer, colorectal cancer, non–small cell lung cancer [NSCLC], pancreatic cancer, renal cell carcinoma, and urothelial cancer) treated at health care practices from 2015 to 2019. Practices were stratified into quintiles based on retrospectively measured rates of NQF 0210, and overall survival was compared by disease type among all patients treated in each practice quintile from time of metastatic diagnosis using multivariable Cox proportional hazard models with a Bonferroni correction for multiple comparisons. Data were analyzed from July 2021 to July 2023.ExposurePractice-level NQF 0210 quintiles.Main Outcome and MeasureOverall survival.ResultsOf 78 446 patients (mean [SD] age, 67.3 [11.1] years; 52.2% female) across 144 practices, the most common cancer types were NSCLC (34 201 patients [43.6%]) and colorectal cancer (15 804 patients [20.1%]). Practice-level NQF 0210 rates varied from 10.9% (quintile 1) to 32.3% (quintile 5) for NSCLC and 6.8% (quintile 1) to 28.4% (quintile 5) for colorectal cancer. No statistically significant differences in survival were observed between patients treated at the highest and the lowest NQF 0210 quintiles. Compared with patients seen at practices in the lowest NQF 0210 quintiles, the hazard ratio for death among patients seen at the highest quintiles varied from 0.74 (95% CI, 0.55-0.99) for those with renal cell carcinoma to 1.41 (95% CI, 0.98-2.02) for those with urothelial cancer. These differences were not statistically significant after applying the Bonferroni-adjusted critical P = .008.Conclusions and RelevanceIn this cohort study, patients with metastatic or advanced cancer treated at practices with higher NQF 0210 rates did not have improved survival. Future efforts should focus on helping oncologists identify when additional therapy is futile, developing goals of care communication skills, and aligning payment incentives with improved end-of-life care.

中文翻译：

---

极晚期实体瘤患者的全身抗癌治疗和总体生存率


重要性美国临床肿瘤学会和国家质量论坛（NQF）这两个著名组织已经制定了癌症质量指标，旨在减少临终时的全身抗癌治疗。这一指标 NQF 0210（在生命最后 14 天接受化疗的患者）受到批评，因为它只关注死者的护理，而不包括可能从治疗中受益的更广泛的患者群体。患有转移性癌症的患者在非常晚期疾病的肿瘤治疗率较高的诊所接受护理时，生存期更长。设计、设置和参与者这项全国范围的队列研究使用了 Flatiron Health，这是一个针对被诊断患有转移性或晚期疾病的患者的去识别化电子健康记录数据库疾病，以确定在医疗机构接受治疗的患有 6 种常见癌症（乳腺癌、结直肠癌、非小细胞肺癌 [NSCLC]、胰腺癌、肾细胞癌和尿路上皮癌）中的一种的成年患者（年龄≥18 岁） 2015 年至 2019 年的实践。根据回顾性测量的 NQF 0210 率将实践分层为五分位数，并使用带有 Bonferroni 的多变量 Cox 比例风险模型，从转移诊断时起在每个实践五分位数中治疗的所有患者中按疾病类型比较总体生存率多重比较的校正。数据分析时间为 2021 年 7 月至 2023 年 7 月。暴露实践水平 NQF 0210 五分位数。主要结果和测量总体生存率。结果 144 个实践中的 78 446 名患者（平均 [SD] 年龄，67.3 [11.1] 岁；52.2% 女性），最常见的癌症类型是 NSCLC（34 201 名患者[43.6%]）和结直肠癌（15 804 名患者[20.1%]）。非小细胞肺癌的实践水平 NQF 0210 比率从 10.9%（五分位数 1）到 32.3%（五分位数 5）不等，结直肠癌的实践水平 NQF 0210 比率从 6.8%（五分位数 1）到 28.4%（五分位数 5）不等。在最高和最低 NQF 0210 五分位数治疗的患者之间，未观察到生存率存在统计学上的显着差异。与在最低 NQF 0210 五分位数的诊所就诊的患者相比，在最高五分位数就诊的肾细胞癌患者的死亡风险比从 0.74（95% CI，0.55-0.99）到 1.41（95% CI， 0.98-2.02）对于尿路上皮癌患者。应用 Bonferroni 调整的临界值 P = 0.008 后，这些差异并不具有统计学意义。结论和相关性在这项队列研究中，在 NQF 0210 率较高的诊所接受治疗的转移性或晚期癌症患者的生存率并未得到改善。未来的努力应该集中于帮助肿瘤学家确定何时额外的治疗是无效的，制定护理沟通技巧的目标，并将支付激励措施与改善临终护理相结合。