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Palliative chemotherapy for patients with end-stage cancer who exhibit promising performance scores should be discouraged, as it does not improve the quality of life for these patients and may actively detract from it, according to a study published in JAMA Oncology.
“Despite the lack of evidence to support the practice, chemotherapy is widely used in cancer patients with poor performance status and progression following an initial course of palliative chemotherapy,” wrote Holly G. Prigerson, Ph.D., of Weill Cornell Medical College, New York. “The goal of palliative chemotherapy for patients with incurable cancer is to prolong survival and promote [quality of life] [but] chemotherapy use among patients with metastatic cancer whose cancer has progressed while receiving prior chemotherapy was not significantly related to longer survival [and] was associated with more aggressive medical care in the patient’s final week and heightened risk of dying in an intensive care unit.”
Dr. Prigerson and her coinvestigators looked at 312 end-stage metastatic cancer patients between September 2002 and February 2008, all of whom were on at least one chemotherapy regimen at one of six outpatient oncology clinics in the United States. They were followed prospectively until death to determine quality of life near death (QOD) as measured by Eastern Cooperative Oncology Group (ECOG) Performance Status scores of 0 (“fully active, able to carry on all predisease performance without restriction”) through 5 (“dead”).
At enrollment, 158 subjects were on chemotherapy and 154 were not. Of the nine subjects with baseline ECOG score of 0, all of whom continued with chemotherapy, six (66.7%) reported lower QOD following treatment. Of 122 subjects with ECOG score 1, 71 of whom continued with chemotherapy, 40 (56.3%) reported lower QOD compared with 35 of the 51 subjects (68.6%) who reported higher QOD after not undergoing chemotherapy. However, as ECOG scores got higher, chemotherapy did appear to be of some benefit to patients.
ECOG score of 2 was found in 116 patients at baseline, of which 55 did chemotherapy and 67 did not; 28 chemotherapy subjects (50.9%) reported lower QOD than at baseline, and 32 (52.5%) of those without chemotherapy also reported lower QOD. For the 58 subjects with ECOG scores of 3, 12 of the 22 who did chemotherapy (54.5%) reported higher QOD after chemotherapy, compared with 19 of the 36 who did not do chemotherapy (52.8%) reporting lower QOD. Finally, seven subjects had ECOG scores of 4 at baseline, of which one did chemotherapy and reported a higher QOD after treatment; of the six who did not, it was a 50/50 split between those with higher and lower QOD.
“Patients receiving palliative chemotherapy with an ECOG performance status of 0 or 1 had significantly worse QOD than did those who avoided chemotherapy [and] no difference in QOD scores was observed by chemotherapy use among those with ECOG performance status of 2 or 3,” the researchers wrote. “Given no observed survival benefit in the studied patients [and] the observed significant association between chemotherapy use and worse QOL in the final week of life among those with a baseline ECOG score of 1, these results highlight the potential harm of chemotherapy in patients with metastatic cancer toward the end of life, even in patients with good performance status,” the investigators said (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2378]).
The study had limitations; specifically, Dr. Prigerson and colleagues did not have complete information about the dose and duration of the chemotherapy used for each patient, as well as detailed information on prior chemotherapy use and the exact specifications of chemotherapy treatments given between baseline assessment and death for each patient.
This study was supported by the National Institute of Mental Health, National Cancer Institute, National Institute of Minority Heath and Health Disparities, Weill Cornell Medical College, and the Health Services Research and Development Service Career Development Award from the Department of Veterans Affairs. Dr. Prigerson did not report any relevant financial disclosures, but two coinvestigators reported associations with pharmaceutical companies.
These data from Prigerson and associates suggest that equating treatment with hope is inappropriate. Even when oncologists communicate clearly about prognosis and are honest about the limitations of treatment, many patients feel immense pressure to continue treatment. 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.
Costs aside, we feel the last 6 months of life are not best spent in an oncology treatment unit or at home suffering the toxic effects of largely ineffectual therapies for the majority of patients. At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit, but if an oncologist suspects the death of a patient in the next 6 months, the default should be no active treatment. Oncologists with a compelling reason to offer chemotherapy in that setting should only do so after documenting a conversation discussing prognosis, goals, fears, and acceptable trade-offs with the patient and family. Let us help patients with metastatic cancer make good decisions at this sad, but often inevitable, stage. Let us not contribute to the suffering that cancer, and often associated therapy, brings, particularly at the end.
Dr. Charles D. Blanke and Dr. Erik K. Fromme are in the division of hematology and medical oncology, Knight Cancer Institute and Oregon Health and Science University, Portland. Neither reported any relevant disclosures. These comments were excerpted from an editorial (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2379]).
These data from Prigerson and associates suggest that equating treatment with hope is inappropriate. Even when oncologists communicate clearly about prognosis and are honest about the limitations of treatment, many patients feel immense pressure to continue treatment. 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.
Costs aside, we feel the last 6 months of life are not best spent in an oncology treatment unit or at home suffering the toxic effects of largely ineffectual therapies for the majority of patients. At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit, but if an oncologist suspects the death of a patient in the next 6 months, the default should be no active treatment. Oncologists with a compelling reason to offer chemotherapy in that setting should only do so after documenting a conversation discussing prognosis, goals, fears, and acceptable trade-offs with the patient and family. Let us help patients with metastatic cancer make good decisions at this sad, but often inevitable, stage. Let us not contribute to the suffering that cancer, and often associated therapy, brings, particularly at the end.
Dr. Charles D. Blanke and Dr. Erik K. Fromme are in the division of hematology and medical oncology, Knight Cancer Institute and Oregon Health and Science University, Portland. Neither reported any relevant disclosures. These comments were excerpted from an editorial (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2379]).
These data from Prigerson and associates suggest that equating treatment with hope is inappropriate. Even when oncologists communicate clearly about prognosis and are honest about the limitations of treatment, many patients feel immense pressure to continue treatment. 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.
Costs aside, we feel the last 6 months of life are not best spent in an oncology treatment unit or at home suffering the toxic effects of largely ineffectual therapies for the majority of patients. At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit, but if an oncologist suspects the death of a patient in the next 6 months, the default should be no active treatment. Oncologists with a compelling reason to offer chemotherapy in that setting should only do so after documenting a conversation discussing prognosis, goals, fears, and acceptable trade-offs with the patient and family. Let us help patients with metastatic cancer make good decisions at this sad, but often inevitable, stage. Let us not contribute to the suffering that cancer, and often associated therapy, brings, particularly at the end.
Dr. Charles D. Blanke and Dr. Erik K. Fromme are in the division of hematology and medical oncology, Knight Cancer Institute and Oregon Health and Science University, Portland. Neither reported any relevant disclosures. These comments were excerpted from an editorial (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2379]).
Palliative chemotherapy for patients with end-stage cancer who exhibit promising performance scores should be discouraged, as it does not improve the quality of life for these patients and may actively detract from it, according to a study published in JAMA Oncology.
“Despite the lack of evidence to support the practice, chemotherapy is widely used in cancer patients with poor performance status and progression following an initial course of palliative chemotherapy,” wrote Holly G. Prigerson, Ph.D., of Weill Cornell Medical College, New York. “The goal of palliative chemotherapy for patients with incurable cancer is to prolong survival and promote [quality of life] [but] chemotherapy use among patients with metastatic cancer whose cancer has progressed while receiving prior chemotherapy was not significantly related to longer survival [and] was associated with more aggressive medical care in the patient’s final week and heightened risk of dying in an intensive care unit.”
Dr. Prigerson and her coinvestigators looked at 312 end-stage metastatic cancer patients between September 2002 and February 2008, all of whom were on at least one chemotherapy regimen at one of six outpatient oncology clinics in the United States. They were followed prospectively until death to determine quality of life near death (QOD) as measured by Eastern Cooperative Oncology Group (ECOG) Performance Status scores of 0 (“fully active, able to carry on all predisease performance without restriction”) through 5 (“dead”).
At enrollment, 158 subjects were on chemotherapy and 154 were not. Of the nine subjects with baseline ECOG score of 0, all of whom continued with chemotherapy, six (66.7%) reported lower QOD following treatment. Of 122 subjects with ECOG score 1, 71 of whom continued with chemotherapy, 40 (56.3%) reported lower QOD compared with 35 of the 51 subjects (68.6%) who reported higher QOD after not undergoing chemotherapy. However, as ECOG scores got higher, chemotherapy did appear to be of some benefit to patients.
ECOG score of 2 was found in 116 patients at baseline, of which 55 did chemotherapy and 67 did not; 28 chemotherapy subjects (50.9%) reported lower QOD than at baseline, and 32 (52.5%) of those without chemotherapy also reported lower QOD. For the 58 subjects with ECOG scores of 3, 12 of the 22 who did chemotherapy (54.5%) reported higher QOD after chemotherapy, compared with 19 of the 36 who did not do chemotherapy (52.8%) reporting lower QOD. Finally, seven subjects had ECOG scores of 4 at baseline, of which one did chemotherapy and reported a higher QOD after treatment; of the six who did not, it was a 50/50 split between those with higher and lower QOD.
“Patients receiving palliative chemotherapy with an ECOG performance status of 0 or 1 had significantly worse QOD than did those who avoided chemotherapy [and] no difference in QOD scores was observed by chemotherapy use among those with ECOG performance status of 2 or 3,” the researchers wrote. “Given no observed survival benefit in the studied patients [and] the observed significant association between chemotherapy use and worse QOL in the final week of life among those with a baseline ECOG score of 1, these results highlight the potential harm of chemotherapy in patients with metastatic cancer toward the end of life, even in patients with good performance status,” the investigators said (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2378]).
The study had limitations; specifically, Dr. Prigerson and colleagues did not have complete information about the dose and duration of the chemotherapy used for each patient, as well as detailed information on prior chemotherapy use and the exact specifications of chemotherapy treatments given between baseline assessment and death for each patient.
This study was supported by the National Institute of Mental Health, National Cancer Institute, National Institute of Minority Heath and Health Disparities, Weill Cornell Medical College, and the Health Services Research and Development Service Career Development Award from the Department of Veterans Affairs. Dr. Prigerson did not report any relevant financial disclosures, but two coinvestigators reported associations with pharmaceutical companies.
Palliative chemotherapy for patients with end-stage cancer who exhibit promising performance scores should be discouraged, as it does not improve the quality of life for these patients and may actively detract from it, according to a study published in JAMA Oncology.
“Despite the lack of evidence to support the practice, chemotherapy is widely used in cancer patients with poor performance status and progression following an initial course of palliative chemotherapy,” wrote Holly G. Prigerson, Ph.D., of Weill Cornell Medical College, New York. “The goal of palliative chemotherapy for patients with incurable cancer is to prolong survival and promote [quality of life] [but] chemotherapy use among patients with metastatic cancer whose cancer has progressed while receiving prior chemotherapy was not significantly related to longer survival [and] was associated with more aggressive medical care in the patient’s final week and heightened risk of dying in an intensive care unit.”
Dr. Prigerson and her coinvestigators looked at 312 end-stage metastatic cancer patients between September 2002 and February 2008, all of whom were on at least one chemotherapy regimen at one of six outpatient oncology clinics in the United States. They were followed prospectively until death to determine quality of life near death (QOD) as measured by Eastern Cooperative Oncology Group (ECOG) Performance Status scores of 0 (“fully active, able to carry on all predisease performance without restriction”) through 5 (“dead”).
At enrollment, 158 subjects were on chemotherapy and 154 were not. Of the nine subjects with baseline ECOG score of 0, all of whom continued with chemotherapy, six (66.7%) reported lower QOD following treatment. Of 122 subjects with ECOG score 1, 71 of whom continued with chemotherapy, 40 (56.3%) reported lower QOD compared with 35 of the 51 subjects (68.6%) who reported higher QOD after not undergoing chemotherapy. However, as ECOG scores got higher, chemotherapy did appear to be of some benefit to patients.
ECOG score of 2 was found in 116 patients at baseline, of which 55 did chemotherapy and 67 did not; 28 chemotherapy subjects (50.9%) reported lower QOD than at baseline, and 32 (52.5%) of those without chemotherapy also reported lower QOD. For the 58 subjects with ECOG scores of 3, 12 of the 22 who did chemotherapy (54.5%) reported higher QOD after chemotherapy, compared with 19 of the 36 who did not do chemotherapy (52.8%) reporting lower QOD. Finally, seven subjects had ECOG scores of 4 at baseline, of which one did chemotherapy and reported a higher QOD after treatment; of the six who did not, it was a 50/50 split between those with higher and lower QOD.
“Patients receiving palliative chemotherapy with an ECOG performance status of 0 or 1 had significantly worse QOD than did those who avoided chemotherapy [and] no difference in QOD scores was observed by chemotherapy use among those with ECOG performance status of 2 or 3,” the researchers wrote. “Given no observed survival benefit in the studied patients [and] the observed significant association between chemotherapy use and worse QOL in the final week of life among those with a baseline ECOG score of 1, these results highlight the potential harm of chemotherapy in patients with metastatic cancer toward the end of life, even in patients with good performance status,” the investigators said (JAMA Oncol. 2015 July 23 [doi:10.1001/jamaoncol.2015.2378]).
The study had limitations; specifically, Dr. Prigerson and colleagues did not have complete information about the dose and duration of the chemotherapy used for each patient, as well as detailed information on prior chemotherapy use and the exact specifications of chemotherapy treatments given between baseline assessment and death for each patient.
This study was supported by the National Institute of Mental Health, National Cancer Institute, National Institute of Minority Heath and Health Disparities, Weill Cornell Medical College, and the Health Services Research and Development Service Career Development Award from the Department of Veterans Affairs. Dr. Prigerson did not report any relevant financial disclosures, but two coinvestigators reported associations with pharmaceutical companies.
FROM JAMA ONCOLOGY
Key clinical point: End-stage cancer patients should not receive chemotherapy because it does not improve quality of life and, in some cases, can harm it.
Major finding: Among patients with good baseline performance chemotherapy status (ECOG score = 1), patients with chemotherapy use versus those without chemotherapy had worse quality of life near death (QOD) (P = .01).
Data source: A multi-institutional, longitudinal cohort study of 312 patients with progressive metastatic cancer, conducted between September 2002 and February 2008.
Disclosures: Study was supported by the National Institute of Mental Health, National Cancer Institute, National Institute of Minority Heath and Health Disparities, Weill Cornell Medical College, and the Health Services Research and Development Service Career Development Award from the Department of Veterans Affairs. Dr. Prigerson did not report any relevant financial disclosures.
