Adult Cancer End of Life Care: Palliative Chemotherapy and Place of Death

Holly G. Prigerson, Ph.D. Irving Sherwood Wright Professor in Geriatrics Professor of Sociology in Medicine Co-Director, Center for End-of-Life Research Weill Cornell Medical College New York Presbyterian Hospital New York City, New York 10065MedicalResearch.com Interview with:
Holly G. Prigerson, Ph.D.
Irving Sherwood Wright Professor in Geriatrics
Professor of Sociology in Medicine
Co-Director, Center for End-of-Life Research
Weill Cornell Medical College
New York Presbyterian Hospital
New York City, New York 10065

MedicalResearch.com: What are the main findings of the study?

Dr. Prigerson: The main outcome of the research was end-of-life treatment and location of death with secondary outcomes being length of survival, late hospice referrals and attainment of preferred place of death. We found that 56 percent of patients receiving palliative chemotherapy in their final months.  Patients treated with palliative chemotherapy were five to 10 times more likely to receive intensive medical care and to die in an intensive care unit (ICU). Fewer than half died at home as compared with two-thirds of patients with metastatic cancer not treated with palliative chemotherapy.

More specifically, we found that palliative chemotherapy was associated with:

  • Increased use of CPR and mechanical ventilation: 14% versus 2%
  • Late hospice referral: 54% versus 37%
  • Death in an ICU: 11% versus 2%
  • Death away from home: 47% versus 66%
  • Death away from their preferred place: 65% versus 80%

Survival did not differ significantly between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11, 95% CI 0.90-1.38). Additionally, patients receiving palliative chemotherapy were less likely to acknowledge their illness as terminal (35% versus 49%, P=0.04), to have discussed end-of-life wishes with a physician (37% versus 48%, P=0.03), and to have completed a do-not-resuscitate order (36% versus 49%, P<0.05).

The reasons for the link are complicated, but they may originate in misunderstanding of the purpose and consequences of palliative chemotherapy.

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. “This study is a first step in proving evidence that specifically demonstrates what negative outcomes may result”.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Prigerson: They may have been unexpected for the oncologists involved in the study, but they were not unexpected for me. In fact, after listening to oncologists note the benefits of palliative chemotherapy, I prompted the study by saying, “Really? You think giving terminally ill cancer patients does more good than harm? Let’s examine that using data from my Coping with Cancer study.”

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Prigerson: “Our results suggest that less use of palliative chemotherapy among patients recognized to have a life expectancy of 6 months or less — or more frequent end-of-life discussions in this group — may reduce intensive end-of-life care and promote earlier access to hospice services, thus improving the quality of advanced cancer patients’ end-of-life care”.

Oncologists should be encouraged to  discuss with patients the implications of palliative care, including potential harms as well as benefits.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Prigerson: The results point to a need for future research to examine and confirm what harms and benefits result from chemotherapy administered in the late stage of cancer, examining survival and also “palliation” or the comfort it provides.  Research is needed to identify patients who are most likely to benefit and most likely to be harmed by palliative chemotherapy and determine if oncologists and patients discuss the likely outcomes of palliative chemotherapy, if that changes the common practice of receiving chemotherapy at life’s end.

Related comments:

“Our results suggest that less use of palliative chemotherapy among patients recognized to have a life expectancy of 6 months or less — or more frequent end-of-life discussions in this group — may reduce intensive end-of-life care and promote earlier access to hospice services, thus improving the quality of advanced cancer patients’ end-of-life care”.

Chemotherapy in the last months of life significantly increased cancer patients’ odds of intensive treatment in the last week of life, late referral to hospice care, and death away from their preferred place, investigators reported.

The findings call into question the benefits of palliative chemotherapy in terminally ill cancer patients.

As many as 50% of patients with incurable cancers receive chemotherapy within the last 30 days of life, despite concerns about the value of such treatment. The American Society of Clinical Oncology identified end-of-life chemotherapy as a practice that could improve patient care and reduce costs if stopped.

Citation:

Wright AA ,Zhang B ,Keating NL ,Weeks JC ,Prigerson HG. Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study. BMJ 2014;348:g1219