Balancing burden and benefit in advanced cancer: Real-world insights into treatment considerations, patterns and outcomes

For patients with advanced cancer, cure is often no longer possible and care focuses on quality of life, symptom burden, and prognosis. Treatment decision‑making is complex and commonly informed by evidence that does not fully reflect routine clinical practice. In this thesis, real‑world data are used to examine treatment patterns, outcomes, and end‑of‑life care in everyday oncology practice. Part 1 examined treatment patterns and outcomes. At the population level, median survival of patients with metastatic cancer improved only modestly over time, despite the introduction of new systemic therapies. Only a minority of patients (15%) received immunotherapy or targeted therapy, among whom survival varied substantially. In metastatic bladder cancer, palliative systemic treatment often could not be continued according to guideline recommendations. In advanced gastric or esophageal cancer, patient or family preference was an important reason to forgo systemic therapy. Treatment patterns and outcomes also differed by timing of metastatic disease: patients with metachronous metastatic breast cancer had less favorable disease characteristics and poorer survival than those with synchronous metastases. The COVID‑19 pandemic had limited impact on treatment patterns, although treatments were initiated slightly earlier. In radiotherapy for bone metastases, hypofractionation was used more often during the pandemic, with persistent variation between centers. Part 2 focused on end‑of‑life care. Pain was highly prevalent in the last week of life, affecting over 80% of patients, with severe pain reported in 35% of patients. Structured symptom monitoring was associated with better pain relief. During the COVID‑19 pandemic, potentially inappropriate end‑of‑life care decreased, mainly due to fewer hospitalizations, ICU admissions and in‑hospital deaths. Potentially inappropriate end‑of‑life care was also associated with poorer well‑being of relatives.