A new study suggests that patients may not benefit from end-of-life chemotherapy — and that for many, their quality of life may worsen in their final weeks compared with patients who forgo last-ditch treatment.
It is an excruciating question for cancer patients with a prognosis of months to live: Should they try another round of chemotherapy?
Guidelines for oncologists say no for very sick patients, those who are often bedridden and cannot handle most daily needs themselves. But for patients who are more self-sufficient, chemotherapy is considered a reasonable option. Despite its well-known toxic side effects, many end-stage patients and their doctors have considered chemotherapy worth trying, believing it may ease discomfort or buy time.
A new study suggests that even those stronger patients may not benefit from end-of-life chemotherapy — and that for many, their quality of life may worsen in their final weeks compared with patients who forgo last-ditch treatment.
“It worsened quality of life for those that are relatively healthy, and those are the ones that the guidelines support treating,” said Dr. Charles Blanke, a medical oncologist at Oregon Health & Science University, who was not involved in the study. “Chemotherapy is supposed to either help people live better or help them live longer, and this study showed that chemotherapy did neither.”
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The study, published Thursday in JAMA Oncology, followed 312 adult patients with a prognosis of six months or fewer to live. The patients, in six oncology clinics across the country, all had solid-tumor cancers that had metastasized. The types included lung, colon, pancreatic and breast cancer, among others. About half opted for end-stage chemotherapy.
After each died, researchers asked the relative or caregiver most knowledgeable about their well-being to rate the patient’s physical and psychological distress and overall quality of life in their last week of life. (The caregivers’ views were considered reliable because their assessment at the study’s outset matched the patients’ own quality-of-life assessments.)
For patients who were more sickly at the start, the caregiver rating of their last week’s quality of life was essentially the same whether they received chemotherapy or not.
But for the 122 patients with fewer symptoms to begin with, results were striking. Of those receiving chemotherapy, 56 percent were reported to have lower quality of life in their last week, compared with 31 percent of those who did not have chemotherapy.
Holly Prigerson, a director of the Center for Research on End-of-Life Care at Weill Cornell Medical College in New York and the study’s principal investigator, said she and colleagues had expected “the exact opposite.”
“The real kicker is it’s the people who are performing well, who are thinking they’re going to benefit, that didn’t,” she said.
Researchers also said there was no difference in survival between chemotherapy and nonchemotherapy groups. However, the study was not devised to measure survival.
Some oncologists said that while the study tackled a difficult question in a careful manner, patients and doctors should avoid generalizing based on its results.
Dr. Thomas Gribbin, an oncologist in Grand Rapids, Mich., noted that patients were seen between 2002 and 2008, before some newer chemotherapy drugs with fewer side effects or the ability to directly target certain tumors or cancer-causing mutations.
“Doctors have been learning who not to treat and I think this captures what we did 10 years ago,” Gribbin said. “A lot of the chemicals we would use today are not necessarily toxic to every organ in your body. And we have improvement in how we manage side effects.”
Most important, he and others said, is that chemotherapy advice to patients should be individualized. “Some patients desire to live as long as possible, some people are looking for excellent quality of life all along, and some people want to hang on three months till their daughter’s wedding,” Gribbin said.
Dr. Lowell Schnipper, chairman of the American Society of Clinical Oncology’s task force on value in cancer care, said the organization’s guidelines, which were based on the likelihood that chemotherapy could diminish end-stage tumors, “not the likelihood of improved quality of life,” should remain for now. But he added that future guideline discussions would likely consider quality-of-life studies.
Christopher Johnson, who died in 2012 at 39 from a rare kidney cancer, received late-stage chemotherapy because he “wanted to do anything he could to prolong his life,” said his mother, Ritchie Johnson, of Sugar Land, Texas.
Looking back, she said in an interview, she would have advised against it because he had “huge side effects.”
“The tumors were still growing, he was in quite a bit of pain, so I don’t see where it made a difference, and the quality of life was just not there,” she said.
Joana Muckalli, of Brooklyn, chose “chemo after chemo” in her long battle with ovarian cancer until shortly before her death last year at 53, said her daughter, Voula. Muckalli “wanted to prolong the chemotherapy,” partly to live until the birth of her first grandchild, her daughter said.
“To our family it seemed the only option,” she said.
The new study was not a randomized trial, which might be ethically impossible, experts said. And some potentially useful information was either unavailable or not reported, including the type of chemotherapy and patients’ previous treatment history.
Quality of life was assessed broadly and only when patients started the study and after death. Prigerson said future studies should include monthly assessments with more detailed questions.
Several experts said it was important to realize that patients’ situations and desires can change.
A patient of Gribbin’s, Brian Whalen, 75, with advanced pancreatic cancer, has chosen chemotherapy. Its side effects are tolerable, he said, and he has survived months longer than initially predicted.
But, he added: “I am not getting better and I do not expect to.”
If side effects worsen or he becomes more disabled, Whalen said he would stop the treatment. “I will not go out miserable. I would hope to be able to smile until my last day.”