Palliative Chemotherapy Is 'Disingenuous Term,' Says Critic

Nick Mulcahy

March 05, 2014

The use of chemotherapy in terminally ill cancer patients is associated with an increased risk for a number of undesirable outcomes, according to a study published online March 4 in BMJ.

Researchers compared 2 groups of terminally ill patients — 216 who received palliative chemotherapy in their final months of life and 170 who did not.

The study participants died a median of 4 months after enrollment.

The patients who received chemotherapy were, among other things, more likely to be younger and to have a better quality of life at enrollment, so the researchers used propensity scoring to balance the groups.

In the last week of life, rates of cardiopulmonary resuscitation, mechanical ventilation, or both were significantly higher in patients who received palliative chemotherapy than in those who did not (14% vs 2%; adjusted risk difference [ARD], 10.5%). Late hospice referrals were also higher (54% vs 37%; ARD, 13.6%).

Furthermore, patients receiving palliative chemotherapy were significantly more likely to die in an intensive care unit (11% vs 2%; ARD, 6.1%) and less likely to die at home (47% vs 66%; ARD, –10.8%).

This is the first study to report an association between palliative chemotherapy and place of death.

Despite the chemotherapy intervention, there was no statistically significant difference in survival between the 2 groups (hazard ratio, 1.11).

When chemotherapy is used to treat metastatic, terminal cancer, it has the "goal of palliating symptoms and improving survival," write senior author Holly Prigerson, PhD, from the Center for End-of-Life Research at Weill Cornell Medical College in New York City, and her colleagues.

Dr. Prigerson believes that the use of chemotherapy at the end of life, and conversation about it, needs reforming. "The term palliative chemotherapy is disingenuous," she told Medscape Medical News in an interview. "There is a negative side to chemotherapy; it makes you sicker."

"Patients, family members, and oncologists all need to be aware of the harms and benefits of palliative chemotherapy and that, despite its name, it may not palliate," she added.

Michael Rabow, MD, agrees about the need for full disclosure. "For all patients, it is time to be clear about the full extent of possible harms," he writes in an accompanying editorial. Dr. Rabow is from the Department of Medicine at the University of California, San Francisco.

 
It is time to be clear about the full extent of possible harms.
 

In this study, "choosing palliative chemotherapy was associated with a whole set of outcomes that may not have been known, expected, or discussed," says Dr. Rabow.

Oncologists who have seen the results of this study told Dr. Prigerson that they provide "some evidence that maybe we are doing more harm than good" with palliative chemotherapy.

Dr. Prigerson and colleagues note that less palliative chemotherapy (when life expectancy is 6 months or less) "may reduce intensive end-of-life care" and "promote earlier access to hospice services."

Those are 2 good things, the authors state, because other research has shown that they improve the quality of a cancer patient's end-of-life care.

Caution Needed

Inga Lennes, MD, from the Massachusetts General Hospital Cancer Center in Boston, praised the study for "shedding light on important issues regarding end-of-life care," including ground-breaking information on place of death in patients who receive palliative chemotherapy.

But she cautioned that this was a retrospective, secondary, exploratory analysis. The data were culled from the prospective Coping with Cancer Study, which involved terminally ill cancer patients and their informal caregivers (such as family).

The original Coping with Cancer Study was subject to selection bias because only 638 (69%) of the 917 eligible patients enrolled, Dr. Lennes pointed out in an interview with Medscape Medical News. Thus, there could have been some influential differences between patients who participated and those who did not, and that bias could have affected this smaller 386-patient study.

"It's hard to draw conclusions from such a heterogenous mix of patients," Dr. Lennes said, referring to the fact that the patients had a variety of tumor types and chemotherapy regimens.

Dr. Prigerson acknowledged that the study data were "messy," and reported that she and some colleagues are planning a prospective study to look at chemotherapy, end-of-life outcomes, and patient wishes.

Dr. Lennes noted that oncologists must negotiate the "dual reality" of patients wanting chemotherapy, even for the smallest benefits, and the potential harms of "aggressive care."

 
We are navigating wishes that are seemingly contrary.
 

Although patients typically want to die at home, they also often want palliative chemotherapy. "We are navigating wishes that are seemingly contrary," she explained.

In fact, more than half of the 386 patients in this study wanted chemotherapy if it would extend their life by 1 week.

This common preference "suggests that cancer patients may not regard chemotherapy as burdensome because they are willing to receive it for a very limited temporal pay-off," write Dr. Prigerson and colleagues.

Terminal cancer patients often misunderstand the intent of end-of-life chemotherapy, according to a number of studies.

In one such study, led by Jane Weeks, MD, from the Dana-Farber Cancer Institute in Boston (a coauthor on the current study), a majority of patients with advanced lung or colorectal cancer mistakenly believed that chemotherapy might cure their disease (N Engl J Med. 2012;367:1616-1625), as reported by Medscape Medical News.

The study was funded by the National Cancer Institute and National Institute of Mental Health. The authors have disclosed no relevant financial relationships.

BMJ. Published online March 4, 2014. Abstract, Editorial

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