Study Shows Palliative Chemotherapy in Patients With End-Stage Cancer Did Not Improve Quality of Life and May Be Harmful
- Although palliative chemotherapy is used to improve quality of life for patients with end-stage cancer, its use did not improve quality of life near death for patients with a moderate or poor performance status, and it worsened quality of life near death for patients with a good performance status. The treatment did not extend survival. ( If you only knew how many times I preached thinking critically about this to my students over the years- tough concept for Americans- John Wayne etc.)
- Chemotherapy use in patients with metastatic cancer with chemotherapy-refractory disease is common. ( so sad so often but not on my watch) ASCO guidelines regarding chemotherapy use in patients with terminal cancer may need to be revised to recognize its potential harm in patients with progressive metastatic disease. ( AMEN)
- Prospective studies of chemotherapy use in patients with end-stage cancer are needed and should include repeated assessments of adverse effects of treatment and designate quality of life and quality of life near death as primary study endpoints.
Although palliative chemotherapy is used to improve quality of life for patients with end-stage cancer, a study evaluating its use found that palliative chemotherapy did not improve quality of life near death for patients with a moderate or poor performance status and that it worsened quality of life for patients with a good performance status. In addition, the treatment did not extend survival.
ASCO guidelines regarding chemotherapy use in patients with terminal cancer may need to be revised to recognize the potential harm of chemotherapy use in patients with progressive metastatic disease, according to the study authors. The study by Prigerson et al is published in JAMA Oncology.
The researchers examined 661 participants enrolled in a prospective multi-institutional cohort study of patients with end-stage cancer and their caregivers. Participants were recruited between September 2002 and February 2008. Patients were required to have a diagnosis of end-stage cancer; a physician-estimated life expectancy of less than or equal to 6 months; be at least 20 years old; have a participating informal caregiver; and have adequate stamina for the interview. A majority of the patients, 384, died during the study observation period and were more likely to be younger, nonwhite, unmarried, uninsured, less educated, and have had a worse performance status at enrollment (all P < .05) than patients who survived. Chemotherapy use at enrollment was unrelated to patients’ being in the deceased vs surviving cohort.
Patients were asked to self-report age, sex, race/ethnicity, years of education, marital status, and health insurance status during baseline interviews conducted at a median of 3.8 months prior to death. Eastern Cooperative Oncology Group (ECOG) performance status was used to evaluate each patient’s performance status at enrollment. In interviews conducted a few weeks after each patient’s death, their caregivers rated the patient’s level of psychological and physical distress and overall quality of life during the patient’s final week.
The investigators found that chemotherapy use was not associated with patient survival, controlling for clinical setting and patients’ performance status. Among patients with a good baseline performance status (ECOG score = 1), chemotherapy use compared with nonuse was associated with worse quality of life (odds ratio [OR], 0.35; 95% CI, 0.17–0.75; P = .01). Baseline chemotherapy use was not associated with quality of life among patients with a moderate baseline performance status (ECOG score = 2; OR, 1.06; 95% CI, 0.51–2.21; P = .87) or a poor baseline performance status (ECOG score = 3; OR, 1.34; 95% CI, 0.46–3.89; P = .59).
“This study demonstrates that palliative chemotherapy does not appear to palliate symptoms, even in the most robust patients who can tolerate chemotherapy,” said Holly G. Prigerson, PhD, lead author of the study, Co-Director of the Center for Research on End-of-Life Care, and the Irving Sherwood Wright Professor in Geriatrics at Weill Cornell Medical College, in a statement. “It raises questions about the rationale for such aggressive, burdensome care.”
“Results of this study suggest that chemotherapy use among patients with chemotherapy-refractory metastatic cancer is of questionable benefit to patients’ quality of life in their final week. Not only did chemotherapy not benefit patients regardless of performance status, it appeared most harmful to those patients with good performance status. ASCO guidelines regarding chemotherapy use in patients with terminal cancer may need to be revised to recognize the potential harm of chemotherapy use in patients with progressive metastatic disease,” concluded the study authors.
Dr. Prigerson is the corresponding author of the JAMA Oncology article.
Conflicts of interest were reported by Thomas W. LeBlanc, MD, MA, who has consulted for Helsinn Therapeutics, Epi-Q, and Boehringer Ingelheim; and Alfred I. Neugut, MD, who has consulted for Pfizer, Otsuka, United Biosource Corportion, and EHE International.
Funding for this study was provided by the National Institute of Mental Health, the National Cancer Institute, the National Institute of Minority Health and Health Disparities, Weill Cornell Medical College, and the Department of Veterans Affairs.