Our Oncology HUB was launched recently inside the Sermo community. The first few months generated a lot of interest and discussion. One of our HUB authors, Dennis Morgan, M.D. contributed his thoughts on palliative chemotherapy asking if the benefits outweigh the negatives. Please read on for his perspective.
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One the most challenging tasks demanded of oncologists is to weigh risks versus benefits. The Hippocratic Oath embodies the concept of “first do no harm”. And yet every physician will appreciate the principle noted in Hamlet, that “Diseases desperate grown By desperate appliance are reliev’d, Or not at all.” But can we justify chemotherapy as our “desperate appliance” to relieve the symptoms of terminal cancer? Recent data points to a need for caution.
ASCO has been identifying opportunities to improve quality and value in cancer care as part of ABIM’s Choose Wisely campaign. At the top of the first such list: “Avoid unnecessary anticancer therapy, including chemotherapy, in patients with advanced solid-tumor cancers who are unlikely to benefit …”. They note that up to 15% of cancer patients get chemotherapy in the last two weeks of life (1).
Undesired consequences of chemotherapy in terminally ill patients have been quantified in a collaborative study amongst researchers at Harvard and Cornell, including the late Jane Weeks (2). The accompanying editorial in the British Journal of Medicine summarizes: compared to patients not receiving palliative chemotherapy within months before death, treated patients were more likely to get CPR, be vented and die in an ICU. Hospice referrals were late, quality of life poorer and costs higher. There was no survival benefit (3).
Chemotherapy is intended to cure, extend or improve life, yet the effort carries substantial risks for adverse, even life threatening side effects. A goal must be kept in focus. The rationale for palliative chemotherapy is that reduction of the tumor burden will alleviate the noxious effects of the tumor. Such an effort is futile when the tumor does not respond or even harmful when the effects of chemotherapy are worse than the disease. In many cases non-chemotherapeutic drugs can be more effective in managing symptoms. My own experience is that many lung cancer patients who were miserable on chemotherapy will undergo gratifying improvement in mood, appetite and breathing comfort with the affordable, convenient and tolerable application of decadron 2 mg tid.
Just as new outcomes-research cautions oncologists in the use of palliative chemotherapy, so patients too should be cautioned. Unfortunately, in far too many cases, oncologists are not making clear the goal of treatment. A study by Jane Weeks et al is sobering: “Overall, 69% of patients with lung cancer and 81% of those with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer.” (4).
Dr. Weeks led the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS). Her obituary in the British Medical Journal notes that “diagnosed as having cancer, her deep knowledge and understanding made her not want to undergo toxic treatments that she knew would not prolong her life but would certainly make her physically miserable. She did not forgo all therapies, but carefully balanced benefits and toxicities in her choices'” (5).
Do you think the use of chemotherapy for palliation needs to be reined back?
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Dennis Morgan has been practicing medicine for over 30 years. He is the Past President of the Connecticut Oncology Association and Assistant Clinical Professor University of Connecticut Health Center.
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