Are preventive drugs overused at the end of life in older adults with cancer?

A new study reveals that preventive medications—such as those to lower blood pressure or cholesterol, or to protect bone health, among others—are commonly prescribed during the last year of life of older adults with cancer, even though they are unlikely to provide meaningful benefits. Published early online in Cancer, a peer-reviewed journal of the American Cancer Society, the findings point to the need for efforts to reduce the burden of drugs with limited clinical benefit near the end of life.

Many older adults take multiple medications concomitantly, which increases the risk of experiencing serious side effects. For older patients with cancer, the benefit of each additional medicine gradually decreases while the risk of harm increases as the illness progresses and prognosis worsens. Benefits may be especially limited for preventive drugs, since these drugs often take several years to achieve their goal. In the context of advanced cancer, the added value of starting or continuing preventive drugs becomes questionable since the patient's remaining life expectancy may be too short to observe any of the intended benefits.

There is limited information on the extent to which such medications are prescribed to patients with advanced cancer before death. Lucas Morin, MS, of the Karolinska Institute, and his colleagues evaluated the prescribing of preventive drugs throughout the final year of life of older adults with cancer who died between 2007 and 2013 across Sweden. The team also estimated the direct costs of such preventive drugs.

Among 151,201 older patients who died with cancer, the average number of drugs increased from 6.9 to 10.1 throughout the last year of life, and the proportion of individuals using 10 or more drugs rose from 26 percent to 52 percent. Preventive drugs—including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics—were frequently continued until the final month of life.

Median drug costs during the last year of life amounted to $1,482 per person, including $213 for preventive therapies. Preventive drugs accounted for approximately one-fifth of the total costs of prescribed drugs, and this proportion decreased only slightly as death approached. Costs for preventive drugs were especially high in older adults who died with pancreatic cancer, breast cancer, or gynecological cancers.

The findings suggest that reducing the use of preventive medications in people with advanced cancer near the end of life has the potential to not only reduce unnecessary side effects and improve patient quality of life, but also to reduce financial burdens for patients.

"Although the preventive drugs reported in our study are most often pharmacologically and clinically appropriate in the general population, their use in the context of limited life expectancy and palliative goals of care should be examined critically," said Morin. "Our finding that older adults with poor-prognosis cancers—including cancers of the brain, lung, liver, and pancreas—were just as likely as those with less aggressive disease to use preventive drugs during their last month of life suggests that there is room for deprescribing."