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Chemo for terminal cancer patients linked to aggressive care

By Kathryn Doyle

NEW YORK (Reuters Health) - Terminally ill cancer patients who received chemotherapy in the last months of life were more likely to die in an intensive care unit than those who did not receive chemo, according to a new study.

Many advanced cancer patients receive chemotherapy that is only meant to make them more comfortable. They often don't realize it will not cure them (see Reuters Health story of June 26, 2013 here: http://reut.rs/1hweUoA ).

Holly G. Prigerson said that in her experience, "palliative chemotherapy" often only makes patients sicker.

Prigerson worked on the new study at the Center for End-of-Life Research of Weill Cornell Medical College in New York City.

"This study arose from a bet I had with an oncology fellow who had argued the benefits of palliative chemotherapy for the dying patient," she told Reuters Health. "I was skeptical."

"Those who received palliative chemotherapy, even after adjustment for their better health and quality of life and treatment preferences at our baseline assessment, were worse off," Prigerson said. "My oncologist colleague was surprised because she was certain chemotherapy would be beneficial."

For the study, the researchers reanalyzed existing data from eight outpatient cancer treatment clinics. Among 386 terminally ill cancer patients, 216 were receiving palliative chemotherapy when the study began.

Those receiving chemo survived about as long - four months, on average - as those who were not. But the circumstances of their deaths were often different.

Fourteen percent of patients on chemotherapy had CPR or were put on a mechanical ventilator, or both, in their last week of life. That compared to two percent of people not on chemo.

Chemo users were more often referred to hospice at the last minute: 54 percent were enrolled within one week of their death, versus 37 percent of people not on chemo.

And 11 percent of chemo patients died in an intensive care unit (ICU), rather than at home, for instance, compared again to two percent of those not on chemotherapy, the researchers reported in the British medical journal BMJ.

"It should be noted that these patients all had cancers that had already worsened on one cancer treatment and therefore these were particularly vulnerable patients," said Dr. Andrew S. Epstein, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City who was not involved in the research.

"Often these cancer treatments in this situation have more risks than benefits, and this needs to be communicated better by doctors and their teams," he said.

With better communication of the risks of chemo at such a late stage, like those found in this study, many patients would not choose it, he said.

Palliative chemo can have benefits for some patients, shrinking tumors, reducing pain and improving quality of life, said Dr. Thomas W. LeBlanc, a cancer and palliative care doctor at Duke Cancer Institute in Durham, North Carolina.

"Like any tool, it must be applied very judiciously," he said. "It does not yield benefits in cases where patients are already significantly debilitated, or have markers of more advanced, refractory disease. It is probably even harmful in such settings."

But it can be very difficult for doctors to recognize exactly the point when chemotherapy goes from being useful to being harmful, said LeBlanc, who wasn't part of the research team.

Patients who get palliative chemo are less likely to want to talk about life expectancy or plan out a "do not resuscitate" order compared to patients who do not, Prigerson said.

"They are more likely to want more aggressive care in general, not make plans to avoid it, become critically ill, possibly as a consequence of the chemo-induced toxicities and then land in the ICU," she said.

"This study, along with other work done by this group, helps paint a picture which suggests that many patients with late-stage cancer are receiving aggressive medical care in ICUs and chemotherapy at the end of their lives, even though this care provides limited to no benefit, undermines their access to care which might better control their symptoms, makes it less likely that they will die in their preferred place of death and is associated with worse overall outcomes for both patients and caregivers," said Dr. Mark D. Siegel, co-chair of the Ethics Committee at Yale-New Haven Hospital in Connecticut.

More work needs to be done exploring ways to foster care that does a better job of treating symptoms and improving quality of life for patients and caregivers, Siegel told Reuters Health. He was not involved in the study.

"For patients to make informed choices of care, they need to know if they are incurable and terminally ill, that palliative chemotherapy is not intended to cure them, that it may not appreciably prolong their life and that it may result in the receipt of very aggressive life-prolonging care that may sacrifice their quality of life," Prigerson said.

SOURCE: http://bit.ly/1ihzPMQ BMJ, online March 4, 2014.

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