Palliative chemotherapy for end-stage cancer does not improve, and may harm, a patient’s quality of life (QOL) in their final week of life, report researchers.
In a study involving 312 patients with end-stage cancer, those who were most active and most able to care for themselves were most likely to be harmed by chemotherapy use near death.
In line with guidelines from the American Society of Clinical Oncology (ASCO), a patient’s level of activity or function – their performance status – is often used as an indicator of whether they will tolerate chemotherapy and benefit from treatment.
In a study headed by Holly Prigerson, professor of sociology in medicine at Weill Cornell Medical College, patients with progressive, metastatic cancer who followed at least one chemotherapy regimen were followed prospectively until death at six outpatient oncology clinics in the United States.
“In the patients with the highest function (e.g. patients most likely to be receiving chemotherapy as in our sample and as per ASCO guidelines), the QOL in the last week of life was significantly and meaningfully lower than in those not receiving chemotherapy at our baseline assessment,” write Prigerson and colleagues in their report of the study, published in JAMA
on 23 July 2015.
To measure QOL close to death, post-mortem interviews were carried out with caregivers. Caregivers were asked to rate the patients’ psychological and physical distress in their final week of life.
Although the benefits of chemotherapy for patients with cancer as they near death have been questioned previously, it has been argued that patients with the highest performance status are most likely to benefit from treatment at this late stage.
“Not only did chemotherapy not benefit patients regardless of performance status, it appeared most harmful to those patients with good performance status,” write Prigerson and colleagues. “ASCO guidelines regarding chemotherapy use in patients with terminal cancer may need to be revised to recognise the potential harm of chemotherapy use in patients with progressive metastatic disease.”
The study raises important questions, says Charles Blanke, professor of medicine in the division of haematology and medical oncology at Oregon Health and Science University’s Knight Cancer Institute, who serves on the ASCO board of directors. It is not clear from the study why patients with end-stage cancer who received chemotherapy had the same observed survival as those who did not. The study included patients with different types of cancer, taking different therapies, and the paper does not make it clear why some patients received treatment while others did not.
Nevertheless, says Blanke: “It is hard not to look at this study as the closest we are likely to come to obtaining proof of the real-world effectiveness of chemotherapy in patients at the end of life with cancer, as a placebo-controlled, double-blind, randomised trial seems unlikely.” The findings are important, he says.
“We believe the efficacy results by Prigerson et al are generally true, represent current practice and stand as a relative indictment of routinely offering chemotherapy to patients with terminal cancers,” writes Blanke in a commentary published in the same issue of JAMA Oncology
Physicians may feel they are depriving a patient of all hope by denying further treatment. This study demonstrates that “equating treatment with hope is inappropriate”, writes Blanke.
“Patients with end-stage cancer are encouraged by friends and family to keep fighting, but the battle analogy itself can portray the dying patient as a loser and should be discouraged,” he argues.
Unlike Prigerson, Blanke does not call for a change to ASCO guidelines. One cannot prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit, he urges. “But if an oncologist suspects the death of a patient in the next six months, the default should be no active treatment,” concludes Blanke.