Chemotherapy in Dying Patients

JAMA continues the wonderful series "Perspectives of Care at the Close of Life" with an article from Dr. Harrington and Dr. Smith from VCU about the timing of chemotherapy in patients with advanced cancer who may be dying (sub req'd). This is particularly relevant because of the recent Dartmouth Atlas report on geographic variability in aggressiveness and costs in the last two years of life despite no large differences in outcomes.

A common opinion is that health care spending is higher then it should be in the last two years/year/6 months of life. Taking this position is clearly a sign of superior skills in prognostication or it demonstrates the ability to use a 'retrospectoscope.' Reading the case presented of a gentleman with metastatic non-small cell lung cancer as he progresses through three lines of chemotherapy will sound familiar to many palliativists. But it is not necessarily obvious when he become 'terminal.' Thus the dilemma of when to shift from curative to palliative care as a primary goal.

The two interviewed physicians in the case do well to show respect for the other, but you still get a sense of the tension that can exist between oncologists and palliative doctors. After being consulted the palliative care doctor called the oncologist and clarified the issues at hand, but they did not explicitly share prognosis as this quote from the palliative care doctor shows:

"They were shocked about the prognosis that I offered . . . of days to weeks. They were still expecting more chemotherapy. Here I was, walking into the room and basically saying, “Okay, folks, it’s time for hospice.”

Curiously as much as prognosis plays a role in these decisions it is somewhat glossed over in the article. This quote from the authors somewhat baffled me:

"When the prognosis is predictable, as with Mr L, why do most oncologists not directly address it?"

The answer to the question is that the prognosis is not always so predictable. We need more prospective studies to demonstrate prognostic skill that so greatly influences decision making. The article quotes many studies showing use of new chemotherapy regimens within a few weeks of someone dying. What is not always clear is was it appropriate to be on the chemotherapy. It is easy to imagine the patient with an ECOG of 4 or PPS of 30 as one of those patients who died within a few weeks after the new chemotherapy started. But what if their ECOG was 2 and the PPS 60 or 70% and they still died. Would you consider that use of palliative chemotherapy appropriate?

These prospective studies of clinician and patient prognostication and the impact on clinical decision making is what medicine needs to better determine if we are making the 'right' decisions at the right time. Looking retrospectively only generally informs us of a existing challenge. It does not provide the answer.

The article is a good read with some great references and an excellent one for the teaching file for oncology and palliative medicine. The focus is not really on prognosis as I have made it here, and what it does cover the authors do an exemplary job. The tables are also particularly notable:

• What Patients Know About Their Advanced Cancer and Its Prognosis
• Palliative Chemotherapy for Metastatic Disease for 4 Common Solid Tumors
• Helpful Questions to Consider Asking About Palliative Chemotherapy
• Things to Do or Say (and Not to Do or Say) About Chemotherapy for Advanced Cancer
• Studies of Concurrent Palliative Care With Oncology Care

The lead author of the article was also one of the selected speakers for the Annual Case Conference for Professionals-in-Training in 2006 at the AAHPM. Way to go Sarah! COngrats on the JAMA publication.

The article was highlighted in USA Today this week, and here are a few of the interesting comments from the website article:

Sorry for the long comment, but I have seen people refuse treatment and die because they were afraid of chemo or something as silly as losing their hair. Chemo is not that bad and has the possibility of extending a life significantly.

As a physician, we don't have crystal balls. To say, you have 5 weeks or 5 months is extremely difficult. We can say based on a certain type of cancer or terminal disease, MOST PEOPLE with this disease typically survive "X" amount of time....but to narrow it down to the individual patient is not feasible. There are many variables.

Palliative care is the wave of the future. These highly trained doctors and nurses do outstanding work with patients and the medical team assigned to those patients. Many times, my sister (the nurse practioner) has had to counsel doctors, interns and other nurses on how to talk to the patient and what to say. She herself has worked with scores of terminally ill patients and their families walking them through the journey, talking directly but gently, and helping them to see the full picture. Hopefully as this unique practice grows, most, if not all, hospitals will have palliative units to help everyone with these difficult issues.

Harrington, S.E., Smith, T.J. (2008). The Role of Chemotherapy at the End of Life: "When Is Enough, Enough?". JAMA: The Journal of the American Medical Association, 299(22), 2667-2678. DOI: 10.1001/jama.299.22.2667