Survival Benefit of Palliative Chemotherapy Often Not Discussed With Patients

Roxanne Nelson

August 01, 2008

August 1, 2008 — Patients with incurable cancer are frequently offered the option of palliative chemotherapy, an intervention that is unlikely to result in a major survival advantage but that can improve tumor-related symptoms. However, most patients receiving treatment in the United Kingdom are not given clear information about the survival gain of palliative chemotherapy, according to a report published online July 31 in BMJ.

Life expectancy in patients with metastatic cancer is often short, and despite improvements in treatment options, survival benefits tend to be modest. Treatment can also be highly toxic, but chemotherapy is increasingly being given closer to the end of life, note Daniel F Munday, MD, a consultant in palliative medicine at Warwick Myton Hamlet Hospice, in the United Kingdom, and E. Jane Maher, MD, consulting oncologist at Mount Vernon Hospital, in Middlesex, United Kingdom, in an editorial that accompanied the study.

"To make informed choices, patients need up-to-date consistent information and comprehensive and expert communication from their oncologists and supportive care teams," write the editorialists.

How information on prognosis and chemotherapy is shared probably influences decisions about palliative care, but it can be difficult to obtain reliable information about prognosis and treatment options in advanced disease, and there is no nationally agreed-upon information about prognosis or risks for palliative chemotherapy, they write. "Most patients say they want full information about diagnosis and prognosis, but do not always receive such information from their oncologist. But they may not necessarily want the whole truth all of the time or want to be fully involved in decision making once information has been received."

Survival benefit is frequently the primary outcome measure in studies concerning palliative chemotherapy, and many patients do place a priority on survival, as opposed to quality of life. "From our results, we found that patients were clearly told that their cancer could not be cured, but it was the actual survival benefit that might be gained from palliative chemotherapy that was not discussed with them," coauthor Jane M. Blazeby, MD, FRCS, professor of surgery and honorary consultant surgeon at the University of Bristol, United Kingdom, told Medscape Oncology.

"We think that for patients to make an informed decision about whether to undergo or not undergo palliative chemotherapy, they need the information about survival benefit, alongside the information about treatment side effects and toxicity and the alternative to receiving supportive treatment alone," said Dr. Blazeby.

The survival gain from palliative chemotherapy is often modest, and tends to be measured in months rather than years, the authors write. Although an offer of active intervention with palliation can support patients as they adjust to their diagnosis, there can be a considerable gap between patient hopes and what is achievable if the survival benefit is not clearly discussed when treatment decisions are being made.

Dr. Blazeby and colleagues undertook this study to evaluate how much information oncologists give their patients about the survival benefit of palliative chemotherapy during consultations at which decisions about treatment are made. Nine oncologists participated in the study, as did 37 patients with advanced non-small cell lung cancer (n = 12), pancreatic cancer (n = 13), and colorectal cancer (n = 12).

Current guidelines in the United Kingdom state that palliative chemotherapy in non-small-cell lung cancer can extend survival by up to 2 months; in pancreatic cancer, it can extend survival from 3 or 4 months to 5 or 6 months; and in colorectal cancer, it can extend median survival of 5 to 9 months to 7.5 to 14 months with single-agent chemotherapy, and 3 to 5 months beyond that with combination therapy.

The consultations between patient and oncologist were digitally recorded, and a researcher observed the office visit to capture nonverbal communication. The recordings were transcribed but kept anonymous to protect privacy and confidentiality.

After analyzing the data, the researchers noted that although there was consistency in informing patients that their disease was not curable and that a cure was not being sought, the amount of information given the patient concerning survival benefits of palliative chemotherapy varied considerably.

The information given to patients about survival benefits included numerical data ("about 4 weeks"), timescales ("a few months extra"), vague references ("buy you some time"), or they weren't mentioned at all. Of the 37 patients, only 6 were given numerical data about the survival benefits of treatment. In 26 of 37 cases, survival benefits were either not mentioned during the visit or the discussion was vague.

Researchers were also able to pinpoint some specific triggers and barriers to discussion of survival benefit. For example, a trigger to discuss survival benefits would be when a patient or relative asked a direct question about it, or the oncologist volunteered the information and gave realistic expectations. The patient might then refuse treatment but at least he or she was aware of the potential benefits of therapy that included extended survival.

Barriers to discussing survival benefits tended to undermine informed consent. As an example, if patients declined the offer of palliative chemotherapy without a thorough discussion of benefits, which included a gain in survival, their decision might be based on inaccurate or incomplete information.

"In our opinion, the reason the survival benefit is not discussed is because oncologists do not want to further upset patients who are already in a vulnerable position," said Dr. Blazbey. "The audio recordings of the consultations showed that in two thirds of consultations, there was no information about survival benefit communicated from the oncologist."

The researchers believe that training for oncologists should include guidance on how to discuss the survival benefits of palliative chemotherapy with their patients. "We think that doctors need to receive advanced-level training in communicating these significant issues," explained Dr. Blazbey. "In the UK, this is part of the latest Department of Health Cancer Reform Strategy."

The study was funded by Cancer Research UK. The researchers have disclosed no relevant financial relationships.

BMJ. Published online before print July 31, 2008.

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