Chemotherapy for Palliative Care

Palliative care is now considered a standard for people with advanced cancer.  That wasn’t true decades ago.

At first chemotherapy palliation was blunt force.  The idea was: give chemotherapy to prevent tumors from growing too big, too fast, thereby inducing pain in the patient.

As with other regimens of chemotherapy tweaking proved to help improve quality of life for the patient.  Combinations were tried and lower doses.  Different drugs were used for different cancers.

Debate

There is an on-going debate about palliative chemotherapy and who should get it.  Is it underused or overused?  Some think palliative therapy use should be given to more patients – all patients with terminal cancer and many others even with a slim chance of survival.

Right now, American Society for Clinical Oncology guidelines recommend this type of  chemotherapy only for solid tumor patients with good performance status.

QOL or quality of life is a term widely used in discussions of palliative care or medicine in a broad sense.  QOD is sometimes used to indicate quality of life near death – some may refer to it as quality of death, although strictly speaking it is more accurately quality of life before death.

A recent study by scientists and doctors at Weill Cornell Medical College found the palliative chemotherapy was associated with negative results for patients with metastatic cancer.  Not only did the chemotherapy fail to extend survival times or improve performance status as measured by Karnofsky Score or Lansky Score, it actually made the patients feel worse.   The researchers found palliative chemotherapy had no significant effect on average quality of life in cancer patients with moderate or poor performance status and worsened QOD for patients with good performance status actually had lower quality of life when they took palliative chemotherapy.  They concludes “the QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death”

Another negative-nelly study found people on palliative chemotherapy are more likely to get into a intensive care unit before they die.  And most would not consider this a positive outcome.  They are more likely to get their heart restarted after a heart attack and to be put on a ventilator.  In general, they are more likely to be treated as if they are hanging on to life.  This stands in contrast to the emerging paradigm of letting people choose where they die.  The study found  65 percent  of people on palliative chemo died in the place of their choice (e.g. home, hospice) versus 80 percent of those without palliative chemotherapy.

Misleading Patients?

More than half of those with cancer deemed to be incurable get palliative chemotherapy in their final months.  Maybe 12 percent get it in the final two weeks of their life, when even the most optimistic oncologists know there is no hope.  (These are US numbers.)

An unfortunate quirk in health literacy shows up in people who are getting palliative chemotherapy.  A study of cancer patients undergoing this type of chemotherapy showed most thought the goal of the drug therapy was to cure the disease or cause long-term remission.  Two-thirds did not understand that their doctors wanted to lessen symptoms with the drugs and that the doctors did not think the cancer would disappear.

There is a huge diversity of patients in terms of disposition, emotional stability, and knowledge of their own health and realistic medicine.  Further, doctors and nurses have a human desire to please their customer.  This leads to a lot of cancer patients over-estimating their chances of survival.  The patients who receive palliative chemotherapy generally have a poor prognosis.

Many critics suspect (with anecdotal evidence) that doctors don’t fully explain palliative chemotherapy to the patients and that this failure is part of a larger problem of leaving the patients with more hope than statistics warrant.  Do the patients understand the treatment is intended to make them feel less sick, not to extend their life?  Even casting aside the patient’s knowledge and expectations, the oncologists may prescribe palliative chemotherapy just as a way of staying with the patients to death.  Doctors don’t want to feel they are abandoning their patients.

Too much optimism can have negative effects.  Patients might put off advance care planning and updating their wills.  Patients, their families, and doctors can let things go when they should be planning for death.

Excuses – Legitimate or Not

One reason palliative chemo may not be as good as we hope for is that nobody directly designs drugs for that purpose.  Chemists at the pharmaceutical companies are trying to find new products with curative action, or at least that can stop or slow cancer growth.  They are not explicitly looking for palliative action.    A review of medicines approved over a 13-year period found that the only 4 of the 57 drugs had approvals that mentioned symptoms and symptom relief.  One criticism is that the QOL metrics are not employed in the formal evaluation process, partly because they are perceived as too subjective and there is no agreed-on way to evaluate QOL.

Palliative chemo drugs are the same drugs used in other contexts and with intentions with the intent to induce remission.  Regimens are developed largely in the field by doctors and patients (sometimes with clinical trial support from pharmaceutical companies).  A systematic method to look for new palliative combinations and regimens could probably help find better methods.

At the 2017 ASCO conference, Drs. Richard Lee and Neal Meropol postulated that three changes could help to bring forward new palliative therapies: 

  • Wide acceptance of PRO (patient-related outcome) within the medical community in assessing validity of anti-cancer treatments and therapies.
  • Regular incorporation of QOL and PRO in phase 1 and phase 2 trials for new medicines.
  • Expanded use of palliative care within current practice guidelines