OAMs at the end: The end of the beginning or the beginning of the end?

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229 Background: In 2001, after three months of review, the FDA approved the oral anticancer agent imatinib, making it the fastest approval in FDA history. Since then, the FDA has approved over 40 oral anti-cancer medications (OAMs) and the number continues to rise, transforming cancer care, improving survival in specific cancers and providing new hope. However, the rapid development of OAMs has produced uncertainty over the best use of these new medications, particularly at the end of life. ASCO guidelines recommend against prescribing intravenous chemotherapy within two weeks of expected death, but no such guidelines have yet been developed for OAMs. We describe one institution’s experience in prescribing OAMs at the end of life. Methods: An interdisciplinary team of pharmacy, oncology and palliative care specialists undertook an IRB-approved retrospective electronic health record review of patients who died between 1/1/2012 and 12/31/2015 and had been on one of seven oral anti-cancer medications (erlotinib, sunitinib, pazopanib, crizotinib, sorafenib, afatinib, regorafenib). From this cohort, descriptors such as diagnosis, stage, prior lines of therapy, ECOG, BMI and albumin were extracted. Results: There were at total of 62 patients who were on at least one of the seven drugs and died during the specified time period. Of these 62 patients, only 2 (3%) had a first prescription for an OAM in the last 30 days of life. Over 90% of the patients that were not prescribed an OAM within 30 days of death were patients with Stage IV disease with a median age of 66 and had an average of 3 prior lines of therapy. Consistent with prognostic models, these patients all had declining albumin, BMI and performance status. Conclusions: Oncologists at this institution rely on prognostic data to gauge when to recommend stopping IV chemotherapy before the last two weeks of life. Extrapolating from ASCO guidelines on the use of IV chemotherapy, these oncologists generally refrain from prescribing OAMs in the last 30 days of life. Unless strong data shows definitive benefit for the use of OAMs, we propose ASCO guidelines recommend not using OAMs during the last two weeks of life.