News & Commentary

Use of Chemotherapy Discouraged For End-Stage Cancer Patients

Chemotherapy for end-stage cancer patients neither lengthens life nor makes the last week of life more comfortable for patients — even those rated as doing fairly well despite their disease, according to a study published in JAMA Oncology. In fact, chemotherapy might actually harm those patients the most while not helping patients who are poorer functioning.

In coming to that conclusion, researchers at New York Presbyterian Hospital put in their crosshairs guidelines by the American Society for Clinical Oncology (ASCO).

“Whereas ASCO guidelines in response to the Choosing Wisely campaign focus on the identification of patients with late-stage metastatic cancer most likely to benefit from palliative chemotherapy, our results suggest these guidelines may identify patients most likely to be harmed by it,” the authors say.

The ASCO guidelines suggest that patients with good “performance scores” are better candidates for chemotherapy than those with low scores. Holly G. Prigerson, the study’s lead author, tells Managed Care that, “It is well known that oncologists give chemo until very late. They think it will help or, at least, don’t think it will harm patients. That’s why this study is so disturbing.”

Patients with end-stage cancer joined the study between September 2002 and February 2008. For this study, end-stage cancer was defined as having distant metastases and cancer that hadn’t responded to prior treatments. In addition, physicians had estimated the life expectancy of these patients to be six months or less.

The researchers compared 158 patients who were receiving chemotherapy when they enrolled in the study with 154 patients who weren’t when they enrolled. The median survival period after enrollment was brief — just 3.8 months.

The main endpoint was the person’s quality of life during his or her last week in life, as rated by the caregiver most knowledgeable about the health care the person received during that week.

The surprise finding was that among seemingly healthier patients (an ECOG performance status of 1), chemotherapy was associated with a poorer quality of life during the patient’s final week of life. Prigerson and her colleagues said the results point to the potential harm of chemotherapy, even in patients who seem to be doing pretty well, despite their cancer.

Among seemingly sicker patients (ECOG performance scores of 2 and 3), chemotherapy was unrelated to the quality of life during the final week.

In an editorial accompanying the study, Charles D. Blanke, MD, and Erik K. Fromme, MD, said it was “disturbing” that this trial demonstrated no benefits of chemotherapy for patients with solid tumors or poor prognosis and “disconcerting” that oncologists still recommend and use systemic therapy so close to patient death.

Patients often want such treatment right up to the “bitter end,” Blanke and Fromme noted. The author Susan Sontag as far back as 1978 (in her book Illness as Metaphor) decried the vocabulary used to describe how patients deal with cancer, a point taken up by Blanke and Fromme as well.

“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,” they write.

Still, the case against chemotherapy for patients with end-stage cancer remains to be made decisively.

Blanke and Fromme said it would be premature to rewrite guidelines that say chemotherapy should be prohibited in patients near death. “But if an oncologist suspects the death of a patient in the next six months, the default should be no active treatment,” they wrote.


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