More on the Questionable Value of Chemotherapy for Terminally Ill Patients

Let us look at more research articles on this often neglected subject of treatment for near death patients.

The effect on survival of continuing chemotherapy to near death

Akiko M Saito, Mary Beth Landrum, Bridget A Neville, John Z Ayanian and Craig C Earle

BMC Palliative Care 2011, 10:14

  • Overuse of anti-cancer therapy is an important quality-of-care issue. An aggressive approach to treatment can have negative effects on quality of life and cost, but its effect on survival is not well-defined.
  • We have previously shown that the aggressive use of chemotherapy in patients who are close to death has been increasing over time.
  • In fact, aggressive approach to treatment during the last week of life is linked to psychological and physical distress for advanced cancer patients.
  • Other studies have also shown that chemotherapy use during near death irrespective of the cancer’s responsiveness to therapy has been associated with potentially negative effects, including higher numbers of emergency room (ER) visits, hospitalizations, and admissions to the intensive care unit (ICU), and less hospice service. These results beg the question of whether aggressive care leads to improved outcomes.
  • Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 7,879 Medicare-enrolled patients aged 65 or older who died after having survived at least 3 months after diagnosis of advanced non-small cell lung cancer (NSCLC) between 1991 and 1999.
  • Receipt of chemotherapy was associated with a 2-month improvement in overall survival. However, based on three different statistical approaches, no additional survival benefit was evident from continuing chemotherapy within 14 days of death.
  • Conclusions: 1. We could not detect a benefit in survival from continuing chemotherapy close to death. Continuing chemotherapy for advanced NSCLC until very near death is associated with a decreased likelihood of receiving hospice care but not prolonged survival.
  • Conclusion 2. Oncologists should strive to discontinue chemotherapy as death approaches and encourage patients to enroll in hospice for better end-of-life palliative care.

Losing “Losing the Battle With Cancer”

Lee M. Ellis, MD; Charles D. Blanke, MD; Nancy Roach

JAMA Oncol. 2015;1(1):13-14.

  • Patients with cancer lose many things of importance. As soon as they hear the words “you have cancer,” they lose control over their lives, as medical appointments immediately begin to shape their daily schedules.
  • They may lose the ability to participate in activities that bring them joy, as a result of chronic treatment adverse effects such as neuropathy, bowel issues, or lymphedema.
  • Too many lose their lives.
  • We also commonly hear the statement that a patient has lost “his or her battle” with cancer.
  • Since President Nixon declared a “War on Cancer” back in 1971, many have used some variant of the term battling cancerin describing all sorts of oncologic treatment, from undergoing locoregional therapies such as surgery and/or radiation therapy, to seeking systemic chemotherapies or biologic therapies, and even pursuing alternative regimens.
  • This is particularly common in advertising campaigns for hospitals or oncology programs. Almost daily we experience some written or broadcast news story on a patient wholost his or her battle with cancer.
  • However, we wish to revisit this topic because there is the need to explain that receiving a diagnosis of cancer should not deny anyone their dignity; no one with cancer should be considered a “loser” in any way during the course of neoplastic disease, including those patients who die of their cancer or effects of their therapy.
  • Using the battle metaphor implies that if a patient fights hard enough, smart enough, and/or long enough, he or she will be able to win the war.
  • Unfortunately, and with rare exceptions, patients with metastatic cancer cannot conquer cancer (win the “war”) no matter how hard they fight. We have far too few effective curative treatments and interventions.
  • We can celebrate occasional long-term survivors, but for the most part, we do not know why one person is alive 15 years after the diagnosis of advanced cancer, whereas another dies 9 months after the diagnosis.
  • Patients with “curable” disease are cured because treatment eradicates every last cell, not because the patient did or did not somehow fight valiantly.
  • Once someone receives a cancer diagnosis, especially advanced-stage disease, a journey begins; sometimes the journey requires patience, tolerance, and courage, but at some point, most patients with advanced disease end that journey with loss of life.
  • Although this difficult and tumultuous journey may have come to an end, dying should not be viewed as being defeated in some kind of skirmish.
  • Many patients themselves adopt the battle metaphor when they receive the diagnosis. If one needs to assume a warlike attitude to face the challenges of cancer, so be it; anything goes in helping a patient (and his or her family) cope during this journey.
  • We have all had the experience of patients stating (paraphrased) “I want curative treatment, not palliative treatment, because I’m going to beat this thing.” The litany of imaging, appointments, examinations, blood sampling, pills, infusions, surgery, and radiation treatments can make a patient feel as if he or she has been in a fight.
  • However, thinking about it from a different perspective, the use of the battle metaphor implies a level of control that patients simply do not have.
  • When we talk about the “battle,” we minimize the real issues faced by patients every day. Patientsdeal with and sometimes overcome nausea, pain, fatigue, and weight loss. They suffer the isolation that comes with a diagnosis.
  • For those with potential curative disease, theylive with the fear of recurrence and impact of chronic adverse effects.
  • Unless you have been in their shoes, it is often hard to imagine the challenges faced every day by our patients, and we oftentimes do not fully credit patients for their persistence and resilience in their journey.
  • Let us recognize them for all the challenges that they overcame in their journey. Let us not declare themlosers at the end of this journey.
  • Similarly, the continuous urge to win the battle extends to oncologists, who actively treat patients for too long. The fact is that 8% of patients receive chemotherapy within 2 weeks of dying of cancer, and 62% within 2 months.
  • Late chemotherapy is associated with decreased use of hospice, greater use of emergency interventions (including resuscitation), and increased risk of dying in an intensive care unit vs at home.This all clearly reflects our society’s need to battle until the end.
  • But let us take a closer look at this mentality. Most of our therapies are toxic: they cause depression of the immune system, fatigue, rash, nausea, vomiting, neuropathy, and so forth. In addition, in today’s insurance landscape, many of our therapies can lead to financial toxicity.
  • Patients are willing to deal with these adverse effects as a trade-off for “hope”— but are we honest with them about the true potential benefit of the treatment?
  • For many therapies, there is little evidence that life is substantially prolonged.
  • We have seen patients who are determined to win their battle. As they turn from treatment to treatment, they are not spending time with loved ones; rather, they are chasing the illusive “win,” a path that affects not only them but also their family and caregivers, as well as family finances.
  • There are patients who face their mortality with clear eyes and, yes, courage. They make choices and can opt to die on their own terms: they can choose to die without a drug-induced rash, diarrhea, or fatigue.
  • They may also choose to spend their remaining time doing what they wish, without an intravenous line or infusion port.
  • They may choose not to be confined to weekly infusions and repeated blood sampling and imaging.
  • Or did she choose to control how she spent her final days? We would venture to say that she made an informed, reasoned decision to say “no more”—no more pain, no more marginal treatment, no more treatment-induced adverse effects: no more!
  • Of course, the choice to end one’s treatment and even one’s life … belongs with the patient. The patient’s decision is informed by their health, their family, their belief system, and, from a pragmatic point of view, their location.
  • We firmly believe that health care professionals owe their patients the difficult and honest discussions that come as patients grapple with their mortality.
  • We also believe that patients’ decisions should be honored and supported by their health care team.
  • Let us respect patients who are already suffering from the effects of cancer and cancer-related therapy.
  • Stuart Scott died of cancer at the age of 49 — seven years after his initial diagnosis and aggressive therapy. In July 2014, in the midst of enduring his cancer and therapy, Mr. Scott told the audience, “When you die, it does not mean that you lose to cancer. You beat cancer by how you live, why you live, and in the manner in which you live.”
  • We will all die one day; perhaps the winner … the person who does it under his or her own terms; the person who dies peacefully and not at war. 

Our last words …

Indeed the above are well-written articles by doctors and scientists. Of course, the world view is that if you have cancer, you need all these stuff — surgery, chemo and radiation or other expensive toxic drugs. Other world views are a no, no — unproven and unscientific, quackery, snake oil, etc. etc. But, after having helped hundreds and hundreds of cancer patients over the past 20 years  with our CA Care Therapy, we have enough evidence to show that non-medical ways to manage cancer, in some cases, are just as effective if not MORE effective, MORE humane and MORE cost effective than the present day chemo and radiation. Why don’t we explore these alternatives? A taboo question indeed to the medical fraternity.

At CA Care, we tell patients. Learn to live with your cancer.” Cancer is not your enemy. So there is no need to wage a war. In war, nobody wins.

We also  tell patients, Everybody has to die — it does not matter if you have cancer or not. So, death is not an issue but a certainty. The important point to consider is how you want to die when the times comes. Don’t die suffering, stripped off human dignity. If you can eat, can sleep, can move about and have no pain … consider yourself blessed. Don’t ask for more. We are indeed very glad to know that most of our patients die in peace without suffering. They also don’t die because of “treatment toxicity” and /or “financial toxicity”.