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Rethinking End of Life Chemotherapy

Posted 7/24/2015

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  This is a truly fascinating and thought-provoking and distressing study from JAMA Oncology that may, over the long run, turn out to be a game changer in oncology care. The article that I will share is from the New York Times, but it was widely reported yesterday. My husband was interviewed as part of an NPR story, and I can promise you that he is intrigued and unsure how to think about this. He makes the very good point that cancer science is increasingly sophisticated and able to identify genetic targets that may make some very ill patients much more likely to respond to treatment--perhaps buying them months of "good" time. But I am getting ahead of myself 

  As reported, the study followed patients from six large cancer centers across the country through the last six months of their illness. They all had solid tumors that had spread and knew they would die from their disease. The standard way of thinking about chemotherapy in this situation is to offer it to people whose overall physical condition is reasonably good. This means that someone who is bed-bound and experiencing daily pain that requires narcotics probably would not be considered "a good candidate" (whatever that means) as opposed to someone who is feeling pretty well, able to maintain many usual activities and enjoying life. The astonishing finding was that individuals, even those whose performance status was quite good and were therefore thought to be likely to benefit, who received chemotherapy did worse than those who stopped treatment and transitioned to palliative care or hospice and tried to make the most of their remaining days without actively fighting back the cancer.

  We all know that any chemotherapy brings side effects. When a person with early chemo is treated for, hopefully, cure, the side effects may be brutal, the feeling being that the benefit of possible cure is worth the cost. But what about someone whose chances of response to the treatment are small (maybe single digits) and who is already certain to die of the disease? Are the side effects then worth it? This is going to stir up lots of conversation and be very difficult and painful for many doctors, patients, and families. It is worth reading and thinking about.

 Benefit of End-Stage Chemotherapy Is Questioned
By PAM BELLUCK

It is an excruciating question for cancer patients with a prognosis of only months to live. Should they try another round of chemotherapy?
Guidelines for oncologists say no for very sick patients, those who are often bedridden and cannot handle
most daily needs themselves. But for patients who are more self-sufficient, chemotherapy is considered a
reasonable option, on the chance it can shrink tumors, prolong or improve life, even for a short while.
Now, a new study suggests that even those stronger patients may not benefit from end-of-life chemotherapy
— and that for many their quality of life may worsen in their final weeks compared with patients who forego
last-ditch treatment.
“It worsened quality of life for those that are relatively healthy, and those are the ones that the guidelines support treating,” said Dr. Charles Blanke, a medical oncologist at Oregon Health and Science University, who was not involved in the study. “Chemotherapy is supposed to either help people live better or help them live longer, and this study showed that chemotherapy did neither.”
The study, published Thursday in JAMA Oncology, followed 312 adult patients with a prognosis of six
months or less to live. The patients, in six oncology clinics across the country, all had solid-tumor cancers that had metastasized. The types included lung, colon, pancreatic and breast cancer, among others. About half opted for end-stage chemotherapy.

http://www.nytimes.com/2015/07/24/health/chemotherapy-may-worsen-end-of-life-quality-study-finds.html

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