When Chemotherapy Does More Harm than Good

Chemo-MORE Harm than-g

One of the news reports above was written by Alice Park,  Time: 23 July 2015. You can read it here: http://time.com/3968918/when-chemotherapy-does-more-harm-than-good/

Some points highlighted in the article:

  • Latest data suggests that chemotherapy can also do more harm than good for some patients.
  • Holly Prigerson, director of the Center for Research on End of Life Care at Weill Cornell Medical College and her colleagues studied the use of chemotherapy among a group of 312 terminal cancer patients. All had been given no more than six months by their doctors, and had failed at least one if not multiple rounds of chemotherapy. About half were on chemotherapy, regardless of its ineffectiveness, at the time of the study.
  • Despite the common assumption that any treatment is better than none, there is not much evidence that chemotherapy is the right choice in these cases—and it may very well be the wrong one.
  • Prigerson’s analysis showed that these patients experience a drop in their quality of life if they get chemo, and that they are therefore worse off than if they hadn’t opted for the treatment.
  • Prigerson said: “The finding that the quality of life was impaired with receipt of the toxic chemotherapy was not surprising. The surprising part was that people who were feeling the best at the start of the therapy ended up feeling the worst. They are the ones most harmed and who had the most to lose.”
  • In other words, the chemo made the patients feel worse without providing any significant benefit for their cancer.
  • Previous studies have shown that chemotherapy in terminal patients is essentially ineffective.
  • And whatever tumor shrinkage occurred wasn’t linked to a longer life.
  • The decision about how long to continue care, including chemotherapy, is up to each cancer patient.
  • Despite explanations from their doctors, many cancer patients still believe that more rounds of chemo will provide some benefit to them, and are therefore reluctant to stop receiving therapy. But at some point, the data shows, more treatment is not better.
  • For patients with end-stage cancer who are still relatively healthy and not feeling sick, additional chemotherapy will likely make them weaker, not to mention eat up more of the precious time they have left traveling to and from infusion centers.
  • Prigerson … hopes the latest findings at least convince doctors to reconsider how they advise their terminal patients about end-stage chemotherapy.

For those who want to believe only in “scientific papers”, let’s go to the study of Dr. Prigerson et al., published in JAMA Oncology: 23, 2015: http://oncology.jamanetwork.com/article.aspx?articleid=2398177

Chemotherapy Use, Performance Status, and Quality of Life at the End of Life

Holly G. Prigerson, PhD1,2; Yuhua Bao, PhD3; Manish A. Shah, MD4; M. Elizabeth Paulk, MD6; Thomas W. LeBlanc, MD, MA5; Bryan J. Schneider, MD7; Melissa M. Garrido, PhD8,9; M. Carrington Reid, MD, PhD2; David A. Berlin, MD10; Kerin B. Adelson, MD13; Alfred I. Neugut, MD, PhD11,12; Paul K. Maciejewski, PhD1,14

  • Physicians have voiced concerns about the benefits of chemotherapy for patients with cancer nearing death.
  • In 2012, an American Society of Clinical Oncology (ASCO) expert panel identified chemotherapy use among patients for whom there was no evidence of clinical valueas the most widespread, wasteful, and unnecessary practice in 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.
  • Available data for patients with NSCLC (non-small cell lung cancer) show a response rate of 2% for third-line and 0% for fourth-line chemotherapy.
  • Although many patients with end-stage cancer are offered chemotherapy to improve quality of life (QOL), the association between chemotherapy and QOL amid progressive metastatic disease has not been well-studied.
  • The goal of palliative chemotherapy for patients with incurable cancer is to prolong survival and promote QOL.
  • We have shown that chemotherapy use among patients with metastatic cancer whose cancer has progressed while receiving prior chemotherapy was not significantly related to longer survival but was associated with more aggressive medical care in the patient’s final week and heightened risk of dying in an intensive care unit.
  • The objective of this study was to examine the effect of chemotherapy use on patient quality of life in the last week of life — QOL near death (QOD). Patient QOD was determined using validated caregiver ratings of patients’ physical and mental distress in their final week. QOD scale: 0 (worst possible) to 10 (best possible).

The results of this study showed that:

  • Chemotherapy use was not associated with patient survival.
  • Among patients with good (ECOG score = 1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOD.
  • Although palliative chemotherapy is used to improve QOL for patients with end-stage cancer, its use did not improve QOD for patients with moderate or poor performance status and worsened QOD for patients with good performance status.
  • The QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death, even in patients with good performance status.
  • Patients receiving palliative chemotherapy with an ECOG performance status of 0 or 1 had significantly worse QOD than those who avoided chemotherapy. No difference in QOD scores was observed by chemotherapy use among those with ECOG performance status of 2 or 3.
  • Given no observed survival benefit in the studied patients with refractory metastatic disease 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 metastasic cancer toward the end of life, even in patients with good performance status.
  • Chemotherapy use in patients with metastatic cancer with chemotherapy-refractory disease is common. A recent study found 62% of NSCLC patients received chemotherapy within 60 days of death.The trend toward more aggressive care of terminally ill patients is increasing and has been noted as a serious problem in the Institute of Medicine’s 2014 report Dying in America.
  • Our results raise questions about the benefits and use of chemotherapy in patients in the end-stage of their illness regardless of their performance status.
  • Our study does highlight the danger of continuing chemotherapy as patients approach the end of life.
  • Results of this study suggest that chemotherapy use among patients with chemotherapy-refractory metastatic cancer is of questionable benefit to patients’ QOL 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.

Let us look at another published article.

Chemotherapy Near the End of Life: First—and Third and Fourth (Line)—Do No Harm

Charles D. Blanke, MD1; Erik K. Fromme, MD.

JAMA Oncol. Published online July 23, 2015. http://oncology.jamanetwork.com/article.aspx?articleid=2398175

  • In reality, only 2 major reasons exist for administering chemotherapy to most patients with metastatic cancer: to help them live longer and/or to help them live better.
  • In exchange for treatment-related toxic effects (as well as substantial time, expense, and inconvenience), chemotherapy can prolong survival for patients with a variety of—though not all—solid tumors.
  • Chemotherapy may also improve quality of life (QOL) for patients by reducing symptoms caused by a malignancy.
  • In this issue ofJAMA Oncology, Prigerson and colleagues report some troubling trial results: chemotherapy administered to patients with cancer near the end of life achieved neither goal.
  • Patients might live longer at the cost of a brief decline in QOL from toxic effects. Patients might also feel better from a reduction of malignancy-related symptoms, even if they do not enjoy improved survival.
  • It is disturbing that this trial demonstrated no benefits of chemotherapy for patients with solid tumors or poor prognosis.
  • And it is disconcerting that oncologists still recommend and use systemic therapy so close to patient death.
  • What does this mean for clinical practice? Must we then just say no to late-line chemotherapy?
  • Patients often want systemic treatment until the bitter end. We have long known a substantial minority of patients with incurable NSCLC would desire chemotherapy, even in the setting of severe toxic effects for a 1-week gain in survival. Similar data exist for patients with breast and large bowel cancers.
  • It is hard to say no to chemotherapy, because doing so could potentially make an oncologist feel they are depriving the patient of all hope.
  • Importantly, this does not mean that the oncologist cannot have a meaningful conversation with most patients about prognosis, especially when there is suspicion that time is limited.
  • 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.
  • 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.

 

 

 

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