Level 2 (mid-level) evidence
Determining the best treatment for patients with end-stage cancer is difficult, with little clinical evidence to guide decision making. Chemotherapy has been used for palliative purposes in patients with metastatic disease who have had disease progression on previous chemotherapy regimens, but there is significant variation in its use at the end of life.
While early palliative care has been shown to improve quality of life and survival in patients with non-small-cell lung cancer (N Engl J Med. 2010;363(8):733-742), palliative chemotherapy in the last month of life may increase the risk of intensive medical treatment and death in an intensive care unit (Ann Oncol. 2011;22(11):2375-2380; BMJ. 2014;348:g1219).
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To further investigate some of these issues, a recent prospective cohort study followed 621 patients with end-stage, progressive metastatic cancer after at least 1 chemotherapy regimen. All patients had a life expectancy of 6 months or less, based on physician estimation. The most common cancers in this study were lung, breast, colon, pancreatic, and other gastrointestinal cancers, which together comprised approximately 70% of all cancers. During the study, 384 patients died. The analysis included 312 patients (81.3%) who were not participating in clinical trials and who had complete data. Of these 312 patients, 50.6% received palliative chemotherapy at baseline, and the distribution of Eastern Cooperative Oncology Group (ECOG) performance status (PS) scores included 39.1% with good performance (PS 1), 37.2% with moderate performance (PS 2), and 18.6% with poor performance (PS 3). Patients receiving chemotherapy were significantly younger (p<0.001) and had better baseline performance status (p<0.001). The patient’s quality of life during their last week of life was assessed through an interview with the caregiver most knowledgeable about the patient’s care at a median of 2.4 weeks after the patient’s death.
Comparing chemotherapy use to nonuse, chemotherapy use was associated with a reduction in the quality of life near death for patients with a good baseline performance status (odds ratio, 0.35; 95% CI, 0.17-0.75). There was no association between chemotherapy use and quality of life near death for patients with moderate or low performance status, however. There was also no significant association between chemotherapy use and mortality.
For patients with poor ECOG performance, this study found no association between palliative chemotherapy and quality of life, in agreement with previous studies. Surprisingly, for patients with good ECOG performance, palliative chemotherapy was associated with a reduced quality of life near death. This is the population most likely to receive palliative chemotherapy and in whom it is thought chemotherapy may provide the greatest benefit.
Palliative chemotherapy was also not associated with improvement in survival, but the study was underpowered to detect differences in this outcome. Overall, the results of this trial suggest that for all patients with end-stage cancer and an estimated life expectancy of 6 months or less, palliative chemotherapy may negatively impact patient quality of life or at best, offer no benefit.
Alan Ehrlich, MD, is a deputy editor for DynaMed, Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester.
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