Aggressive end-of-life care among over half a million patients with cancer in Shandong, China, 2017–2022

Background: Aggressive cancer care near the end of life (EoL) often yields limited benefits and may even diminish patients' quality of life. Research on EoL cancer care from low- and middle-income countries (LMICs) remains scarce. As China experiences accelerated population ageing, a large number of cancer deaths, and rapid expansion of hospital capacity and medical technologies, it is important to assess the trends and determinants of aggressive EoL care among patients with cancer. Methods: This cross-sectional study used linked hospital discharge and death registry data, including 594,415 adult patients who died of cancer between 1 January 2017, and 31 December 2022 in China. Aggressive EoL cancer care was measured using several internationally validated indicators, including chemotherapy use, multiple hospitalisations, and intensive care unit (ICU) admissions near the EoL. A modified Poisson regression model was applied to identify associated factors. Results: Among patients who died of cancer, 20.7% experienced at least one type of aggressive end-of-life care. From 2017 to 2022, the proportion of EoL ICU admissions increased from 0.9% to 2.8%, aggressive chemotherapy use rose from 4.1% to 4.8%, and multiple hospitalisations increased from 16.2% to 18.3%. Male sex, younger age, stable income, social health insurance with higher reimbursement rates, and comorbidities were factors significantly associated with a higher risk. Conclusions: This study offers a comprehensive analysis of aggressive EoL cancer care in an LMIC setting, revealing rising trends and key predictors. The findings underscore the urgent need to prioritise people-centred EoL care in rapidly evolving LMIC healthcare systems, while minimising unnecessary hospital-based interventions.