What If Chemo Doesn't Help You Live Longer Or Better? | KUOW News and Information

What If Chemo Doesn't Help You Live Longer Or Better?

Jul 23, 2015
Originally published on July 24, 2015 8:10 am

Chemotherapy given to patients at the end of life often does more harm than good, according to a study that calls into question this common practice.

We're not talking here about standard chemotherapy, which can be used to greatly prolong life and sometimes cure cancer. Instead, the study published online Thursday, in the medical journal JAMA Oncology, focuses on chemotherapy given to people with solid tumors who have been diagnosed with terminal disease and aren't expected to live more than six months.

"Chemotherapy is not meant to cure people like that," says Holly Prigerson, director of the Cornell Center for Research on End-of-Life Care.

Even so, people with advanced cancer are sometimes given chemotherapy with the hope that it might slightly prolong their lives or make them more comfortable.

Prigerson and her colleagues decided to see whether chemotherapy in this circumstance actually does improve a patient's quality of life. So they talked to the patients' caregivers and asked them how the patient fared during the final week of life.

"They assessed things like their mood, how anxious they were, their physical symptoms and their overall quality of life," Prigerson says. Her study found that chemotherapy often harmed these patients at the end, reducing their quality of life. And it didn't extend their lives, either.

This was even the case for patients who had been able to keep active and felt relatively OK when this new round of chemotherapy began.

"The conventional wisdom," Prigerson says, "is that patients and oncologists think, 'Why not? I have nothing to lose.' And I think the wake-up call from these data, really, is to say, 'There are harms being done, and there is a cost to getting chemo so late.' "

She acknowledges that some people may still opt for chemotherapy in these circumstances. But she thinks patients and doctors need to better understand the pluses and minuses of treatment at the end of life.

"I think some patients would say, 'I don't care, I want to be on chemotherapy; it gives me something to do and it makes me feel that I'm fighting my cancer,' " she says. "That's fine, if patients know that the likelihood of them benefiting from that chemotherapy is still remote, and it will probably make them feel sicker because of toxicities and side effects of the treatment."

But doctors should not encourage that approach to cancer care, says Dr. Charles Blanke, an oncologist at Oregon Health and Science University's Knight Cancer Institute.

"I think this paper strongly argues that giving chemotherapy near the end of life — that is, in patients with terminal cancer — should not be the default, and oncologists should have a darn good reason if they want to do so," Blanke says.

In an editorial accompanying the research paper, Blanke and Dr. Erik Fromme, an internist and palliative care specialist at OHSU, argue that it's time to change this accepted medical practice. They write that "equating treatment with hope is inappropriate."

"If the doctor really doesn't expect you to be around in six months, it's probably better to focus your time on something that's not chemotherapy," Blanke tells NPR. He focuses instead on pain relief, mood issues, sleep disturbances and other problems that can affect a patient's quality of life.

Dr. Lowell Schnipper, who heads oncology at Beth Israel Deaconess Medical Center, helped draft treatment guidelines at the American Society of Clinical Oncology. He says he's not ready to abandon them just yet.

"I think this is a wake-up call to talk to our patients," Schnipper says.

Patients do need to hear a doctor say that a situation is truly dire when it is, he agrees. But each patient is different, he says, and novel approaches may sometimes be worth trying even in patients like this.

Still, Schnipper says doctors haven't spent enough time considering quality-of-life issues in these circumstances.

"That is actually an important gap in our research knowledge, and this paper might actually be a step toward filling that gap," Schnipper says.

New Medicare rules also pay doctors to take the time to discuss end-of-life issues, and oncologists say that step could help get more of these conversations started as well.

Copyright 2017 NPR. To see more, visit http://www.npr.org/.

ROBERT SIEGEL, HOST:

Doctors offer chemotherapy to patients even when the end of life is near, hoping the treatment will make them feel better and possibly prolong their survival. NPR's Richard Harris reports on a new study that finds that this end-of-life treatment often harms a patient's quality of life.

RICHARD HARRIS, BYLINE: Chemotherapy often helps cancer patients live for many more years, and it can even be considered a cure. But there comes a time for some cancer patients when doctors know the treatment has failed and patients with advanced cancer likely have less than six months left to live.

HOLLY PRIGERSON: Chemotherapy is not meant to cure people like that.

HARRIS: Holly Prigerson at the Weill-Cornell Medical College says those patients are still sometimes given chemotherapy with the hope that it might slightly prolong their lives or make them more comfortable. She and her colleagues decided see whether chemotherapy in this circumstance actually does improve a patient's quality of life. So they talked to the patient's caregivers and asked them how the patient fared during the final week of life.

PRIGERSON: They assessed things like their mood, how anxious they were, their physical symptoms and their overall quality of life.

HARRIS: A report in the journal JAMA Oncology finds that chemotherapy often harmed these patients at the end, reducing their quality of life, and it didn't extend their lives either. This was even the case for patients who had been able to keep active and felt relatively OK when this new round of chemotherapy was started.

PRIGERSON: The conventional wisdom is that patients and oncologists think, why not? I've nothing to lose. And I think the wake-up call from these data really is to say, well, there are harms being done, and there is a cost to getting chemo so late.

HARRIS: Prigerson says some people may still opt for chemotherapy in these circumstances, but she says patients and doctors need to better understand the pluses and minuses of treatment at the end of life.

PRIGERSON: I think some patients would say, I don't care; I want to be on chemotherapy. It gives me something to do, and it makes me feel like I'm fighting my cancer. That's fine if patients know that the likelihood of them benefitting from getting that chemotherapy is still remote, and it will probably make them feel sicker because of toxicities and side effects of the treatment.

CHARLES BLANKE: I think this paper strongly argues that giving chemotherapy near the end of life, that is in patients with terminal cancer, should not be the default and oncologist should have a very darn-good reason if they want to do so.

HARRIS: Dr. Charles Blanke at the Oregon Health and Science University says it's time to change this accepted medical practice. Doctors, he says, too often equate treatment with hope.

BLANKE: If the doctor really doesn't expect you to be around in six months, it's probably better to focus your time on something that's not chemotherapy.

HARRIS: For example, pain relief, mood issues, sleep disturbances and other problems that can affect a patient's quality of life. But Dr. Lowell Schnipper, who helped draft guidelines at the American Society for Clinical Oncology, says he's not ready to abandon them just yet.

LOWELL SCHNIPPER: I think this is a wake-up call to talk to our patients.

HARRIS: He says patients do need to hear a doctor say that a situation is truly dire when it is. But each patient is different, and novel approaches may sometimes be worth trying, even in patients like this. Still, Schnipper says doctors haven't spent enough time to consider quality of life issues in these circumstances.

SCHNIPPER: That is actually an important gap in our research knowledge, and this paper might actually be a step towards filling that gap.

HARRIS: New Medicare rules also pay doctors to take the time to discuss end-of-life issues, and that could help as well. Richard Harris, NPR News. Transcript provided by NPR, Copyright NPR.