End‑of‑life care in advanced melanoma: a retrospective cohort study from an Italian comprehensive cancer center

Despite improvements in overall survival (OS) with immune-checkpoint inhibitors (ICIs) and targeted therapies, many patients with advanced melanoma and non-melanoma skin cancer still experience disease progression (PD) and remain on systemic therapy during the End of Life (EoL) phase. Evidence on treatment patterns, healthcare utilization, and palliative care integration in the last weeks of life remains scarce. We conducted a retrospective cohort study including consecutive patients with advanced skin cancers treated in a single Italian comprehensive cancer center who died from advanced skin cancer between 2015 and 2021. Data from the last six months of life on systemic therapies, radiotherapy, hospital admissions, emergency department (ED) visits, specialist consults, palliative care, and place of death were analysed. Descriptive statistics and logistic regression were applied to identify predictors of healthcare use. A total of 93 patients were included (melanoma n = 84, cutaneous squamous cell carcinoma (CSCC) n = 7, Merkel cell carcinoma (MCC) n = 2). In the last six months of life, 88 (95%) received systemic therapy, mostly ICIs (n = 66, 71%); among patients with BRAF-mutant melanoma, 33 (72%) received BRAF/MEK inhibitors. At three months before death, 80 (86%) patients remained on active treatment. Imaging was performed frequently, with a median interval between the last CT scan and death of 48 days (interquartile range 26–85). During the last six months before death, palliative care involvement was limited: 14 (15%) had an outpatient palliative care consult, while 59 (63%) received home-based palliative assistance. Hospitalizations occurred in 55 (59%), and 45 (48%) had ≥ 1 ED visits in the last six months. Home-based palliative care showed a tendency to decrease ED visits (OR 0.43; 95% CI 0.13–1.3; p = 0.1) during the last three months of life. Place of death was home for 47 patients (51%), hospital for 32 (34%), and palliative care unit (PCU) for 10 (11%). Most patients with advanced cutaneous malignancies remained on systemic therapy until the last 12 weeks of life, with high healthcare use and scarce integration of palliative care. These findings underline the importance of earlier and systematic palliative care involvement, alongside pragmatic decision-making, to reduce ED visits and optimize quality of life near the EoL phase.