Letting Go: No Reduction in Aggressive Care for Advanced Cancer

Kate Johnson

June 09, 2016

CHICAGO — Despite being "widely recognized to be harmful to patients and their families," aggressive care is still administered to the majority (75%) of patients with incurable metastatic cancer, concludes a new study.

The finding, reported here at the American Society of Clinical Oncology (ASCO) 2016 Annual Meeting, also shows that the society's own recommendations are being ignored.

More data are needed to show that this practice leads to "misery," said an expert not involved with the study.

"The responsibility is with physicians to do a better job clarifying the goals of care with their patients and further understanding the patient's goals and priorities," said lead study author Ronald Chen, MD, from the University of North Carolina at Chapel Hill.

"Toward the very end of life, this is especially important because continued aggressive treatment would likely cause side effects but be unlikely to significantly extend a patient's life. This type of discussion can help reduce the overuse of aggressive care and, frankly, we probably have to have the discussion repeatedly because as the cancer progresses and the end of life gets closer, these goals may change," he told Medscape Medical News.

No Impact of Recommendation

ASCO issued a strong recommendation against cancer treatments in late metastatic disease, encouraging instead a shift to palliative symptom relief in its first set of Choosing Wisely recommendations, issued in 2012.

But the study by Dr Chen's team, which involved 28,371 patients from the HealthCare Integrated Research Database, suggests that the ASCO recommendation has had no influence on clinical practice.

The researchers looked at people with metastatic cancer who died from 2007 to 2014; 12,764 had lung cancer, 5207 had colorectal cancer, 5833 had breast cancer, 3397 had pancreatic cancer, and 1508 had prostate cancer.

Dr Ronald Chen

Both before and after the ASCO recommendation against aggressive end-of-life care, about 75% of patients received care that "could be considered aggressive," said Dr Chen.

"This included about two-thirds of patients who were admitted to the hospital or the emergency room in the last 30 days. About 29% of patients received intensive care, and one-third of patients died in the hospital instead of dying at home," he explained.

"In addition, about 25% to 30% of patients received chemotherapy in the last 30 days of life. Radiation therapy was used the least of all the categories we looked at — about 15% to 20% received that. And 25% to 30% of patients received invasive procedures," he reported.

Dr Chen said the root of this is likely twofold.

"We have a desire as physicians to help our patients when a cancer progresses by offering them treatments, and we're not very good at realizing when a patient is at the end of life. I think this combination is probably the most likely reason for the overuse of aggressive care," he said.

"I am not indicating that we should hold back chemotherapy or radiation from patients; that is not it," he elaborated in an interview with Medscape Medical News. "If they continue to have progression through the first, the second, the third treatment, and as it becomes less effective and causes more side effects, I think we need to have more and more discussions. Maybe some people want to continue with aggressive treatment all the way to the end — and that would be okay — but I think we need to have more discussion."

But Holly G. Prigerson, PhD, director of the Cornell Center for Research in End of Life Care in New York City, had stronger words for what she calls "this pernicious pattern of care."

"Patients, their family members, and oncology providers need to know how aggressive end-of-life cancer care affects society, individual patients, and even their family caregivers," she told Medscape Medical News. "They need the evidence of noxious outcome."

At the moment, she said, hope is what continues to drive treatment.

"Our research shows that oncologists feel pressure — both internal and external — to offer hope. They feel compelled to do something even if they have no proof that that something will be helpful. Patients and families are grasping at straws; chemotherapy is that straw. And there is definitely pressure from family members to try something — anything — even if, as is often the case, patients have had enough," she said.

She suggested there need to be more studies on the way aggressive care affects quality of life — "what this type of care costs and what it actually buys (i.e., misery, not good quality of life). The outcomes data on progression-free survival need to be linked to outcomes that have meaning for patients, such as the ability to achieve accomplishments on a proverbial bucket list."

Ultimately, she said, it will take more than ASCO recommendations to achieve a meaningful reduction in aggressive end-of-life care. "I don't think oncologists base their practice on ASCO guidelines. The guidelines are essentially a recommendation without incentives or penalties. To put it a bit crassly, human behavior is driven by rewards and punishments, and ASCO guidelines fall into neither category."

The ASCO recommendations also advocate earlier involvement of palliative care specialists and hospice care — services that were used by only 14% to 18% of patients in the study, said Dr Chen.

He said greater access to these services, even concomitant with aggressive care, could facilitate a change.

"We may have a culture where palliative care and aggressive treatment are antagonistic, but they're really not; they're complementary," he said. "Even when a patient is getting aggressive chemotherapy and radiation, I think we should still be able to involve palliative care specialists because they can help us, even when a patient's getting treatment, to maximize their quality of life by taking care of their side effects. And they can also help us clarify these discussions about transition along the cancer journey."

Dr Chen reports receiving research funding from Accuray and serving in a consulting or advisory role for Medivation/Astellas. Dr Prigerson has disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2016 Annual Meeting: Abstract LBA10033. Presented June 6, 2016.

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