Immunotherapy Versus Hospice: Treatment Decision-Making in the Modern Era of Novel Cancer Therapies

Purpose of Review Modern advances in cancer treatment with immunotherapy have created substantial hope for patients and oncologists alike due to a new possibility of durable response which can verge on "cure." This, in combination with a more favorable toxicity profile, has led many oncologists to consider immunotherapy for patients who might have previously been recommended for hospice. In this narrative review, we discuss (1) the risks and benefits of immunotherapy in patients with far advanced cancer in the last months of life, (2) the role of supportive and palliative care, and (3) how to navigate complex treatment decisions for these patients. Recent Findings Unfortunately, data on immunotherapy outcomes for patients with poor performance status and far advanced disease are quite limited. Where available, studies consistently report poorer survival outcomes compared to patients with preserved performance status. However, a minority of patients (15-30%) may achieve at least partial response with immunotherapy, which can be quite durable. Such prognostic uncertainty leads to additional challenges in treatment discussions and decision-making. Given such prognostic uncertainty, clinicians should individualize treatment with consideration for all the various factors that may inform each patient's expected outcome with immunotherapy. Early involvement of palliative care in the disease trajectory can help patients with advanced cancer to optimize their quality of life, improve illness understanding, navigate prognostic uncertainty, and facilitate complex decision-making regarding cancer treatments. With upfront, open discussions of immunotherapy expectations, oncologists can help ensure treatments are aligned with patient goals and optimize value outcomes.