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Palliative chemotherapy fails to improve quality of life near death
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Palliative chemotherapy did not improve quality of life near death for patients with end-stage cancer who had a moderate or poor performance status and worsened quality of life near death for patients with a good performance status, according to study findings.
“This study demonstrates that palliative chemotherapy does not appear to palliate symptoms even in the most robust patients who can tolerate chemotherapy,” Holly G. Prigerson, PhD, director of the Cornell Center for Research on End-of-Life Care at Weill Cornell Medical College, said in a press release. “It raises the question about the rationale for such aggressive, burdensome care.”
Although palliative chemotherapy is often used to improve quality of life for patients who have end-stage cancer, data on chemotherapy and quality of life for patients with progressive metastatic disease had been lacking.
Prigerson and colleagues examined the association between ECOG performance status and the effect of chemotherapy on quality of life during the last week of life.
The analysis included 312 patients (mean age, 58.6 years; 54.8% men) from a multi-institutional, longitudinal cohort study of patients with end-stage cancer. Overall, 50.6% of patients were receiving chemotherapy at the time of enrollment.
Researchers assessed ECOG performance status at baseline (median 3.8 months prior to death). Nine patients (2.9%) had an ECOG score of 0, 122 patients (39.1%) had a score of 1, 116 patients (37.2%) had a score of 2, 58 patients (18.6%) had a score of 3, and 58 patients (18.6%) had a score of 4.
Analyses adjusted for clinical setting and patients’ performance status indicated chemotherapy use was not associated with survival (HR = 0.85; 95% CI, 0.65-1.11).
Researchers noted the effects of chemotherapy use on quality of life near death (QOD) varied according to ECOG score.
Among patients with an ECOG score of 1 — or good baseline performance status — chemotherapy use appeared to be associated with a worse QOD compared with no chemotherapy (OR = 0.35; 95% CI, 0.17-0.75).
Additionally, chemotherapy did not improve QOD among patients with an ECOG score of 2 — defined as moderate performance status — (OR = 10.6; 95% CI, 0.51-2.21) or 3, a poor performance status (OR = 1.34; 95% CI, 0.46-3.89).
This study follows a previous paper published in 2014 in British Medical Journal in which Prigerson and colleagues found that patients receiving palliative chemotherapy were less likely to die at home, more likely to die in an ICU and more likely to receive aggressive treatments and interventions.
“Although we did not find a survival advantage associated with use of chemotherapy, this study was not designed to examine survival,” Prigerson said in the release. “We have proposed further research to examine this explicitly. Nevertheless, these data show that incurable cancer patients with a limited life expectancy who use chemotherapy are likely to impair the quality of their remaining days. Oncologists may presume there to be no harm in giving dying patients chemotherapy, but these data point to more harm than benefit.”
Charles D. Blanke
In an accompanying editorial, Charles D. Blanke, MD, FACP, FASCO, professor of medicine in the division of hematology and medical oncology at Oregon Health and Science University’s Knight Cancer Institute and a HemOnc Today Editorial Board member, and Erik K. Fromme, MD, MCR, FAAHPM, associate professor of medicine and medical director for the Oregon Health and Science University Palliative Medicine and Comfort Care team, suggest although these findings are “troubling,” rushing to change guidelines for the use of palliative chemotherapy in patients nearing the end of life may be premature.
“These data … suggest that equating treatment with hope is inappropriate,” Blanke and Fromme wrote. “At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit.” – by Anthony SanFilippo
Disclosure: Prigerson reports no relevant financial disclosures. Other researchers report consultant roles with Boehringer Ingelheim, EHE International, Epi-Q, Helsinn Therapeutics, Otsuka, Pfizer and United Biosource Corp. Blanke and Fromme report no relevant financial disclosures.
Perspective
Back to TopJeanie Youngwerth, MD, and Jean S. Kutner, MD, MSPH
The 2013 Institute of Medicine (IOM) report, “Delivering High-Quality Cancer Care,” concludes that the cancer care delivery system is in crisis. The report describes the need to improve the value in cancer care, where higher quality is achieved and costs are made affordable to decrease disparities in access to high-quality cancer care for patients and families. The 2014 IOM report, “Dying in America,” focuses on improving quality of life for people with serious illness, as well as their quality of death, which tends to get less attention despite the fact that everyone will experience death for herself/himself and loved ones.The Prigerson and colleagues study helps to address quality of life near the end of life for people with end-stage cancer. The study looks at the association of quality of life near death — defined as the quality of life in the last week of life — for patients receiving chemotherapy with progressive, metastatic cancer. The patient population was diverse, recruited from a broad range of institutions and studied as a prospective cohort. The authors clearly defined “end-stage cancer” as distant metastasis and disease refractory to one or more lines of chemotherapy, along with a physician-estimated prognosis of 6 months or less, which is a clinically relevant definition of end-stage illness, as this also defines hospice eligibility for patients with cancer.
The study results may be a surprise to some — patients with a high performance status (ECOG 1), who would be expected to benefit most from chemotherapy, were found to have an association with the worse quality of life near death. Chemotherapy use in patients with lower performance status (ECOG 2 or 3) was not associated with worse quality of life near death. Although not studied as a primary outcome, no survival benefit was observed regardless of baseline performance status.
A provocative study such as this tends to raise more questions than it may answer. When should we stop recommending further chemotherapy in patients with limited life expectancy, regardless of performance status? Do patients with higher initial performance status — who would be expected to tolerate chemotherapy better — fall harder? How would involvement of palliative care or hospice with the care of these patients and their families have affected their quality of life in the last months and weeks of life? This question is particularly relevant given the growth of palliative care and the July announcement of Medicare hospice demonstration projects permitting hospice services concurrently with disease-focused treatments.
Of interest from this study would be to examine the quality of life near death for those who survived the study period, to evaluate how close to death chemotherapy was stopped for patients, if biologic therapies were included as “chemotherapy” regimens, and to examine the quality of life periodically throughout the study period, in addition to the last week of life.
This study continues to humble us as clinicians — more is not always better. Prigerson and colleagues have stimulated people to talk about end-of-life care and to inform how we can best improve quality during this important time of life, just as the IOM reports hoped to do. Focusing on person-centered care is of priority and includes having a thorough discussion of the risks, benefits and burdens of therapies, and to support alternatives to chemotherapy — including the option of hospice care — in patients with progressive metastatic disease.
References:
CMS. Medicare care choices model. Available at: innovation.cms.gov/initiatives/Medicare-Care-Choices/. Accessed July 29, 2015.Institute of Medicine. Delivering high-quality cancer care. Available at: www.nap.edu/catalog/18359/delivering-high-quality-cancer-care-charting-a-new-course-for. Accessed July 29, 2015.
Institute of Medicine. Dying in America. Available at: www.nap.edu/catalog/18748/dying-in-america-improving-quality-and-honoring-individual-preferences-near. Accessed July 29, 2015.
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