Treating terminally ill cancer patients with chemotherapy in the months or weeks before death doesn’t improve quality of life and may actually do more harm than good, according to new research.
The findings challenge widespread clinical practice as well as accepted treatment guidelines—and could underscore the need for clinicians to re-evaluate the common use of chemotherapy at the end of patients’ lives.
A majority of the end-stage cancer patients in a new study received so-called palliative chemotherapy. Oncologists largely assume that in these patients, whose remaining life expectancy is six months or less, the treatment eases symptoms and extends survival. But neither of those effects was found to be true.
Best for patients
Among the patients who at the start of the study were generally healthiest and most active, palliative chemotherapy use was associated with worse quality of life in their last week of life and showed no benefit to overall survival. Those who were less healthy at the study’s outset experienced no net effect from the treatment, both in quality of life and survival.
The American Society for Clinical Oncology (ASCO) recommends restricting the use of palliative chemotherapy to highly functioning patients because they are presumed to be most likely to benefit from it. Conversely, ASCO recommends chemotherapy be avoided in patients who are bed-ridden more than 50 percent of their waking hours and have reduced or no ability to care for themselves.
Routinely giving patients who have been feeling relatively well a palliative treatment that is toxic and can result in side effects is likely to make patients feel worse, not better, says Holly G. Prigerson, co-director of the Center for Research on End-of-Life Care and the Irving Sherwood Wright Professor in Geriatrics at Weill Cornell.
“This study demonstrates that palliative chemotherapy does not appear to palliate symptoms even in the most robust patients who can tolerate chemotherapy. It raises questions about the rationale for such aggressive, burdensome care.”
Quality of life
The current work builds on a previous paper published last year in the British Medical Journal that showed that people who received palliative chemotherapy were less likely to die at home, more likely to die in an intensive care unit, and more likely to receive aggressive interventions. But that study did not address whether the medicine provided any benefits.
For the new study, published in JAMA Oncology, researchers examined 661 end-stage patients with advanced metastatic disease and cancer progression following prior chemotherapy regimens who were enrolled in their long-term, multi-institutional study.
About four months before death, investigators used a scale called the Eastern Cooperative Oncology Group (ECOG) Performance Status to determine patients’ health and functioning and whether they were receiving chemotherapy. In interviews conducted a few weeks after each patient’s death, their caregivers rated their level of psychological and physical distress and overall quality of life in the week before they died.
Just over half of the participants were receiving palliative chemotherapy at the beginning of the study. All of the patients with an ECOG score of zero—indicating that they were fully active and had no symptoms or functional impairment—were receiving chemotherapy at that time.
Patients with ECOG scores of zero or 1 (meaning they were ambulatory and able to carry out light work) who were receiving chemotherapy at study entry had significantly lower quality of life at the end of their lives than those who were not receiving chemotherapy.
Strikingly, among patients with an ECOG score of 1, only 45 percent of those who were receiving chemotherapy had a high quality of life score (seven or above on a 10-point quality of life scale) in the week before death. Among those who were not receiving chemotherapy, 70 percent had a high quality of life score.
“Although we did not find a survival advantage associated with use of chemotherapy, this study was not designed to examine survival. We have proposed further research to examine this explicitly,” Prigerson says.
“Nevertheless, these data show that incurable cancer patients with a limited life expectancy who use chemotherapy are likely to impair the quality of their remaining days. Oncologists may presume there to be no harm in giving dying patients chemotherapy, but these data point to more harm than benefit.”
Source: Cornell University