The rates of administering chemotherapy to patients with solid cancers within a month of succumbing to their disease remain high, which calls for a paradigm shift to consider initiating palliative care at an earlier stage and formulating clear guidelines for end of live care, according to findings of a large audit presented on 8 October at the ESMO 2016 Congress in Copenhagen, Denmark.
Chemotherapy is often administered near the end of life for solid cancer patients with the intent to ease symptoms but is usually ineffective and toxic, according to lead author Phillipe Rochigneux, Medical Oncology, Institute Paoli-Calmettes, Marseille, France. Dr. Rochigneux presented findings on behalf of collegues from a review of the data concerning the use of chemotherapy at the end of life throughout France and the factors associated with its use.
The investigators designed a nationwide, register-based study that included all patients hospitalised in France between 2010 and 2013 who were aged 20 years and older who died having metastatic solid tumours. They used multivariate analyses to identify patients, tumour, and the facility level characteristics associated with chemotherapy use. Specific sub-analyses were also computed to investigate the role of the putative chemosensitivity of the tumour, as defined by a response rate of the tumour to standard first line chemotherapy > 30% (literature data).
Higher rates of end of life chemotherapy reported in hospitals without palliative care units
Data regarding 279,846 metastatic solid cancers in end of life patients were included in the register.
The rates of chemotherapy administration near the end of life were 39.1% during the last 3 months, 19.5% during the last month, and 11.3% within the final 2 weeks.During their last month of life, 6.6% of patients started or resumed a chemotherapy regimen.
Patient characteristics that associated by multivariate analysis with lower rates of chemotherapy included female sex (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.93, 0.98) older age (OR 0.70; 95% CI 0.69, 0.71 for each 10-year increase), and a higher number of chronic comorbidities (OR 0.83; 95% CI 0.82, 0.84) were independently associated with lower chemotherapy rates.
Patients were more likely to receive chemotherapy during the last month of life if their tumours displayed chemosensitivity to standard first line chemotherapy (OR 1.21; 95% CI 1.18, 1.25). Another factor that independently associated with end of life chemotherapy were patients having cancer types for which major therapeutic innovations occurred between the years 2005 to 2010 (OR 1.17; 95% CI 1.14,1.20).
End-stage chemotherapy rates were also higher in patients dying in a for-profit hospital compared with university hospitals (OR 1.40; 95% CI 1.34,1.45), and in patients in comprehensive cancer centres (OR 1.43; 95% CI 1.36,1.50). Higher than average rates of chemotherapy were reportedly administered near the end of life in high-volume cancer centres and in hospitals lacking palliative care units (OR 1.21; 95% CI 1.18, 1.24).
Stein Kaasa who discussed the study findings said that patients want to live as long and as good as possible. However, he questioned if it should mean access to chemotherapy close to death. He also questioned if the goal is to reduce the use of chemotherapy close to death - how to do it? The way is to establish a relationship with the patients which is “more than only tumour focused” (addressing emotional and family issues, considering the use of advanced directives), perform systematic symptom and function assessments, communicate the prognostic information to the patients.
Early palliative care can contribute to more balanced use of chemotherapy during end of life, better symptom management, better emotional function and better family care. A total integration with the right use of palliative care resources will also help out in a hectic oncology outpatient clinic, but the palliative care specialist need to have competences on oncology.
Chemotherapy rates near the end of life remain high in patients with metastatic solid cancers. These rates are especially high in young patients, being treated in high-volume centres, which lack a palliative care unit.
There is an urgent need to decrease the aggressiveness of end of life treatments by making and implementing clear guidelines for end of life care, to initiate palliative care earlier on, and to reinforce supportive care training for oncologists and other cancer professionals.
Use of chemotherapy near the end of life for solid cancers: What factors matter?
P. Rochigneux, J.L. Raoul, L. Morin
This study was funded by the Paoli-Calmettes Institute (Marseille Cancer Center), and the Aging Research Center of Karolinska Institutet, Stockholm.