End-of-life chemotherapy: Does it do more harm than good?
The decision over if or when to stop chemotherapy is a heart-wrenching one many cancer patients and their families eventually face. Now a new study, published online today in JAMA Oncology, suggests that for those near the end of their lives, the treatment may do more harm than good.
"Palliative chemotherapy is designed not to cure patients, but to improve symptoms and hopefully extent their lives," lead study author Dr. Holly Prigerson, Director of the Center for Research on End-of-Life Care at Weill Cornell Medical College, told CBS News. "So, we wanted to look at whether patients who were getting palliative chemotherapy had better of worse quality of life."
What they found was not good news. Giving chemotherapy to end-stage cancer patients near death was associated with worse quality of life among those who could still perform many daily life functions. The results also found that chemotherapy had no effect on the quality of life on less-functional patients close to death.
Prigerson and her team followed over 300 patients with end-stage cancer whose tumors had spread to other parts of their bodies. They all were all unresponsive to at least one if not multiple rounds of chemotherapy, and doctors estimated their life expectancy to be six months or less. At the time of the study, about half of the patients received chemotherapy and half did not.
The patients' level of daily function was assessed by ranked their ability to perform activities such as walking, light work, and self-care. And about two weeks after the patients' deaths, a family member or other caregiver rated the patients' quality of life during the last week before death.
For patients who were still able to perform daily life activities, chemotherapy was associated with worse quality of life in the week prior to death.
"It was the patients that were feeling good that had the most to lose by taking chemo before their death," Prigerson said. "So why were these patients who were unlikely to benefit being given chemotherapy? If the purpose was to improve the quality of life, these findings really raise questions about the legitimacy of that claim."
In an accompanying editorial, Dr. Charles D. Blanke and Dr. Erik. K. Fromme, of the Oregon Health & Science University in Portland, acknowledged that the decision to stop chemotherapy is extremely difficult and many doctors may feel pressured to continue treatment to avoid depriving the patient of hope.
However, they write: "These data from Prigerson and associates suggest that equating treatment with hope is inappropriate."
Further complicating the issue, patients may feel pressured by those close to them 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," Blank and Fromme wrote.
Experts say oncologists need to have meaningful and realistic conversations with patients about their prognosis, especially if it is suspected that the end of life is approaching.
"The thinking has been 'these patients have nothing to lose,'" Prigerson said. "But this data shows, yes, they do. There is being harm done."
"At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit," Blank and Fromme conclude, "but if an oncologist suspects the death of a patient in the next six months, the default should be no active treatment."