New findings from the Coping with Cancer study raise troubling questions about the scant benefits and potential harms of palliative chemotherapy during the final weeks of a patient’s life. A key problem is that many patients with terminal cancer mistakenly believe palliative chemotherapy can offer cure—and too many clinicians are “uneager” to clarify matters, the new study’s lead author tells ChemotherapyAdvisor.com. Frank discussions about end-of-life goals and planning should occur early and repeatedly throughout cancer treatment.
Chemotherapy for terminally ill patients “may do more harm than good,” concluded Holly Prigerson, PhD, of Weill Cornell Medical College in New York City, NY, lead author of a newly published study on end-of-life cancer care.1
Patients undergoing chemotherapy during their final weeks of life were more likely to experience painful, aggressive procedures and to die in the intensive care unit (ICU) rather than at home, Dr. Prigerson told ChemotherapyAdvisor.com.
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Her team’s analysis of data from 386 participants in the federally funded Coping with Cancer study found that 216 (56%) of the patients with terminal cancer received palliative chemotherapy. These patients saw no survival benefits from end-of-life chemotherapy but they faced higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both, during their last week of life (14% vs 2%).1
Patients receiving chemotherapy were also far more likely than other patients to die in an ICU (11% vs 2%) and to be referred to hospice late, within a week of death (54% vs 37%), the study showed.1
“It’s hard to see in these data much of a silver lining to palliative chemotherapy for patients in the terminal stage of their cancer,” Dr. Prigerson said. “Until now, there hasn’t been evidence of harmful side effects of palliative chemotherapy in the last few months of life.”
The study provides the beginning of a much-needed evidence base, and lends new weight to concerns that end-of-life care too frequently eschews quality-of-life considerations.2-4 For example, another newly reported study suggests that palliative chemotherapy during the winter holidays might needlessly deny patients the opportunity to spend holiday time at home with families, one last time.3 The findings also bolster the identification by the American Society of Clinical Oncology of end-of-life chemotherapy as a practice that, if curtailed, could improve patient care and reduce medical costs.5
Honest Communication of Prognosis Is Key to Patient Decision-making
Most patients with cancer misunderstand palliative chemotherapy to be a curative treatment, Dr. Prigerson said. Worse, given the deep desire among terminally ill patients and their loved ones to believe that palliation might be curative, is the fact that many oncologists are “uneager” to clarify matters, she was quick to add.
That can lead to patients avoiding pressing end-of-life issues.
“We found that patients who received palliative chemotherapy were less likely to acknowledge that they were terminally ill, to discuss end-of-life care they would want to receive if they were dying, and less likely to complete a DNR [do-not-resuscitate] order,” Dr. Prigerson said.
Clinicians should discuss end-of-life planning with patients much earlier than they tend to do, Dr. Prigerson said, starting at the time of diagnosis, at least for the cancers involved in the new study (gastrointestinal and thoracic cancers).