Chemotherapy and quality of life at the end of life

Chemotherapy for patients with end-stage cancer was associated with worse quality of life near death for patients with a good ability to still perform many life functions, according to an article published online by JAMA Oncology.
Physicians have voiced concerns about the benefits of chemotherapy for patients with cancer who are nearing death. An American Society of Clinical Oncology (ASCO) expert panel has called chemotherapy use among patients for whom there was no evidence of clinical value the most widespread, wasteful and unnecessary practice in oncology.

Holly G. Prigerson, Ph.D., of Weill Cornell Medical College, New York Presbyterian Hospital, New York, and colleagues examined the association between chemotherapy use and quality of life near death as a function of patients' performance status, which ranks their ability to perform activities such as be ambulatory, do work and handle self-care.

Chemotherapy use (158 patients were receiving it at study enrollment or 50.6 percent) and performance status were assessed at baseline (a median of about four months before death) and 312 patients with progressive metastatic cancer were followed. The majority of patients were men and the average age of patients was 58.6 years.

Study results showed that chemotherapy was not associated with improved quality of life near death for patients with moderate or poor ability to perform functions. But chemotherapy was associated with worse quality of life near death compared with nonuse of chemotherapy for patients with a good ability to still perform life functions.

"Not only did chemotherapy not benefit patients regardless of performance status, it appeared most harmful to those patients with good performance status. ASCO guidelines regarding chemotherapy use in patients with terminal cancer may need to be revised to recognize the potential harm of chemotherapy use in patients with progressive metastatic disease," the study concludes.

Commentary: Chemotherapy Near the End of Life

In a related commentary, Charles D. Blanke, M.D., and Erik. K. Fromme, M.D., of the Oregon Health & Science University, Portland, write: "These data from Prigerson and associates suggest that equating treatment with hope is inappropriate. Even when oncologists communicate clearly about prognosis and are honest about the limitations of treatment, many patients feel immense pressure to continue treatment. ... At this time, it would not be fitting to suggest guidelines must be changed to prohibit chemotherapy for all patients near death without irrefutable data defining who might actually benefit, but if an oncologist suspects the death of a patient in the next six months, the default should be no active treatment," the author concludes.