Sunday, June 7, 2009

Chemotherapy at the end of life

Annals of Oncology has an article about the use of chemotherapy at the end of life. It's a retrospective cohort study from a single cancer center in Australia, looking at all patients who had died (N=750; median age 67 years; 20% with lung cancer and the rest with a smattering of everything else) from incurable solid tumor malignancies between 2005 and 2007 (patients who died while receiving treatment with curative intent were excluded).

Only 4 and 10% of patients received chemotherapy during the last 2 and 4 weeks of life, respectively. This is significantly lower than recent US figures (which are in the 15-20% range for the last 2 weeks of life). Age, gender, country of origin, type of cancer did not predict receiving chemotherapy in the last month of life. However, treating oncologist did - there were distinct and significant differences between individual oncologists (rates ranged from 8% to 28%). There was a strong trend (not reaching statistical significance) for individual oncologist being a predictor of receiving chemo in the last 2 weeks of life as well.

Some caution here: this was a univariate analysis and it's possible that certain oncologists treated different types of cancers which lead to the differences. However, when they actually looked at if type of cancer predicted receiving late chemo it didn't which would suggest this is not the case at least with these data. (They anecdotally suggest in their comments as well that at this center all the oncologists treat all cancer types.)

This is a disturbing finding. The type of care you receive (including the circumstances of how you die) should ideally be determined by you/your values and what's medically available/reasonable - not by which doctor you happen to get assigned to. You wouldn't want to die in an ICU against your wishes just because of who your PCP happens to be and this isn't any different. There will always be variations in practice, style, approach, etc. - of course. A more than 3-fold difference however, again assuming these oncologists were seeing similar mixes of patients, is an indication that the type and quality of care was being determined by something other than patients and what's medically reasonable. Always, but in particular at life's end, the care patients receive should be 'about them' (for them, to meet their goals, etc.) and not 'about us' as doctors and what we are and aren't comfortable with. I'm not particularly aware of other studies which have shown this phenomenon (about individual docs) but they may be out there (please comment on them if you know of them). (In the Coping with Cancer Study, regional variations made a big difference for, perhaps, comprehensible reasons.)

They also mention this issue, which I guess is important in the Australia, too:

Another possible explanation for the continuation of chemotherapy at the end of life is that recommending a new course of chemotherapy to patients is often an easier option than discussing cessation of chemotherapy and transition to palliative care with them and their caregivers. It is ironic that in both the United States and Australia, oncologists receive financial reimbursement for chemotherapy delivery but little or no reimbursement for the time-consuming and emotionally difficult process of family conferences or end-of-life discussions.
Even at the academic center I work at, in which there is no direct or really indirect financial incentive for my colleagues to prescribe chemotherapy, there is a distinct lack of compensation/incentive for talking with patients at length (I know because that's what I do and it's not very reimbursable). The sad thing is, in oncology and elsewhere, the vast majority of people want to do the right thing but we've created this system for ourselves which effectively punishes us for doing that as it means we see fewer patients in a day, or spend longer hours doing the right thing without any commensurate compensation.

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