Terminal cancer patients receiving chemotherapy during the last months of their lives are more likely to undergo invasive medical procedures rather than dying peacefully where they want to, than those who do not receive chemotherapy, as suggested by research in this week's BMJ. The findings underscore a disconnect between the type of care many cancer patients say they want and the kind they receive, and highlight the need for clearer and more balanced discussion of the harms and benefits of palliative chemotherapy at the end of life by doctors, patients and families, the study authors say.
The Dana-Farber Cancer Institute and Weill Cornell Medical College study found sobering outcomes for patients who received palliative chemotherapy - treatment designed to prolong survival and ease symptoms, but not to cure disease - among patients whom physicians had determined had six or fewer months to live. Whereas 80 percent of patients who did not receive palliative chemotherapy died where they wished, only 68 percent of those whose disease management included palliative chemotherapy died in the place they wanted to. Nearly 66 percent of patients who did not receive palliative chemotherapy died at home, compared to 47 percent of patients who received palliative chemotherapy. And patients who received palliative chemotherapy were much more likely than their counterparts to die in an intensive-care unit - a contrast of 11 to 2 percent.
"Our finding that patients with terminal cancers were at higher risk of receiving intensive end-of-life care if they were treated with palliative chemotherapy months earlier underscores the importance of oncologists asking patients about their end-of-life wishes," said Alexi Wright, MD, MPH, an assistant professor and medical oncologist at Dana-Farber Cancer Institute and lead author on the study. "We often wait until patients stop chemotherapy before asking them about where and how they want to die, but this study shows we need to ask patients about their preferences while they are receiving chemotherapy to ensure they receive the kind of care they want near death."
"It''s hard to see in these data much of a silver lining to palliative chemotherapy for patients in the terminal stage of their cancer," said senior author Holly Prigerson, PhD, the Irving Sherwood Wright Professor in Geriatrics and Palliative Medicine at Weill Cornell Medical College. "Until now, there hasn''t been evidence of harmful effects of palliative chemotherapy in the last few months of life. This study is a first step in providing evidence that specifically demonstrates what negative outcomes may result. Additional studies are needed to confirm these troubling findings."
The reasons for the link are complex, but may originate in patients'' misunderstanding of the purpose and likely consequences of palliative chemotherapy and lack of acknowledgment of their own prognoses, said Prigerson, who recently came to Weill Cornell from Dana-Farber Cancer Institute in Boston. In the study, patients getting palliative chemotherapy were less likely to talk to their oncologists about the care they wanted to receive if they were dying, to complete Do-Not-Resuscitate orders, or to acknowledge they were terminally ill, she noted. With 56 percent of patients receiving palliative chemotherapy in their final months, the findings underscore the potential harms of aggressive use of chemotherapy in dying patients, and the possible need for widespread changes in oncology practice at academic medical centers.
The scientists analyzed data from 386 patients in the federally funded Coping with Cancer study, which followed terminally ill people and their caregivers until after the patients died. During the six-year study, researchers examined how psychosocial factors influenced patients'' care. In the month after the patients died, caregivers were asked to rate their loved ones'' care, quality of life, and place of death as being where the patient would have wanted to die. The investigators then reviewed patients'' medical charts to determine the type of care they actually received in their last week.
Even after the researchers took into account characteristics such as age, marital status, whether a patient had health insurance, their overall physical and mental health, and the treatment they preferred, those who received palliative chemotherapy still underwent more invasive medical procedures in the last week of their lives and in more cases died in ICUs than patients who did not receive palliative chemotherapy. Among those interventions were CPR and mechanical ventilation.
Patients who received palliative chemotherapy were also more likely to be referred to hospice care, which provides comfort care and emotional support, a week or less before they died. Some 54 percent of patients receiving palliative chemotherapy were referred to hospice late, compared to about 37 percent of patients who weren''t taking the drugs.
"The results highlight the need for more effective communication by doctors of terminal prognoses and the likely outcomes of chemotherapy for these patients," said Prigerson, who was the principal investigator on the Coping with Cancer study. "For patients to make informed choices about their care, they need to know if they are incurable and understand what their life expectancy is, that palliative chemotherapy is not intended to cure them, that it may not appreciably prolong their life, and that it may result in the receipt of very aggressive, life-prolonging care at the expense of their quality of life."
The results should not be taken to mean that patients should be denied or not offered palliative chemotherapy, however. "The vast majority of patients in this study wanted palliative chemotherapy if it might increase their survival by as little as a week," added Wright. "This study is a step towards understanding some of the human costs and benefits of palliative chemotherapy."
The study was funded by the National Cancer Institute and National Institute of Mental Health.
Co-authors on the study were, from Weill Cornell, Baohui Zhang, from Dana-Farber, Dr. Jane C. Weeks, and from Harvard Medical School, Dr. Nancy L. Keating.
About Dana-Farber Cancer Institute
Dana-Farber Cancer Institute is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center, designated a comprehensive cancer center by the National Cancer Institute. It provides adult cancer care with Brigham and Women''s Hospital as Dana-Farber/Brigham and Women''s Cancer Center and it provides pediatric care with Boston Children''s Hospital as Dana-Farber/Boston Children''s Cancer and Blood Disorders Center. Dana-Farber is the top ranked cancer center in New England and fifth nationally, according to U.S. News & World Report, and one of the largest recipients among independent hospitals of National Cancer Institute and National Institutes of Health grant funding.
About Weill Cornell Medical College
Weill Cornell Medical College, Cornell University''s medical school located in New York City, is committed to excellence in research, teaching, patient care and the advancement of the art and science of medicine, locally, nationally and globally. Physicians and scientists of Weill Cornell Medical College are engaged in cutting-edge research from bench to bedside, aimed at unlocking mysteries of the human body in health and sickness and toward developing new treatments and prevention strategies. In its commitment to global health and education, Weill Cornell has a strong presence in places such as Qatar, Tanzania, Haiti, Brazil, Austria and Turkey. Through the historic Weill Cornell Medical College in Qatar, the Medical College is the first in the U.S. to offer its M.D. degree overseas. Weill Cornell is the birthplace of many medical advances - including the development of the Pap test for cervical cancer, the synthesis of penicillin, the first successful embryo-biopsy pregnancy and birth in the U.S., the first clinical trial of gene therapy for Parkinson''s disease, and most recently, the world''s first successful use of deep brain stimulation to treat a minimally conscious brain-injured patient. Weill Cornell Medical College is affiliated with NewYork-Presbyterian Hospital, where its faculty provides comprehensive patient care at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. The Medical College is also affiliated with Houston Methodist. For more information, visit weill.cornell.edu.