National Trends in the Use of Palliative Therapy in Stage IV Rectal Cancer in the United States

Background: Palliative-intent therapies are a key component in the management of metastatic rectal cancer; however, contemporary national trends and disparities in their utilization remain incompletely characterized. Methods: A retrospective cohort study was conducted using the National Cancer Database (NCDB) from 2012 to 2023. Adult patients with stage IV rectal adenocarcinoma were included. Palliative therapy was defined using the NCDB variable indicating treatment administered with non-curative intent. Temporal trends were evaluated overall and stratified by facility type and median household income. Multivariable logistic regression was performed to identify independent predictors of palliative therapy utilization. Results: A total of 43 443 patients were included, of whom 8931 (20.6%) received palliative-intent therapy. Utilization increased significantly over time, from 16.2% in 2012 to 25.6% in 2023 (p < 0.001). Systemic therapy was the most frequently used modality and increased over time, while surgical palliation declined substantially. Immunotherapy use rose markedly in later years. Palliative therapy utilization increased across all facility types. Across all income strata, utilization also increased, with the most pronounced rise among patients from lower-income areas. On multivariable analysis, lower income (OR 1.82, 95% CI 1.21–2.74), brain metastases (OR 5.75, 95% CI 1.76–18.70), and immunotherapy use (OR 1.65, 95% CI 1.24–2.21) were independently associated with increased odds of receiving palliative therapy, whereas primary tumor resection was associated with reduced utilization (OR 0.45, 95% CI 0.32–0.61). Conclusion: In this large national cohort, palliative therapy utilization increased modestly over time, with a shift from surgical to systemic approaches. These patterns, observed across diverse healthcare settings and socioeconomic groups, reflect the evolving integration of palliative-intent treatment in the modern management of metastatic rectal cancer.