References: JAMA Oncol 2015 Jul 23 early online (level 2 [mid-level] evidence)
Determining the best treatment for patients with end stage cancer is difficult, with little clinical evidence to guide decision making. Chemotherapy has been used for palliative purposes in patients with metastatic disease who have had disease progression on previous chemotherapy regimens, but there is significant variation in its use at the end of life (Ann Oncol 2015 Jul;26(7):1440). While early palliative care has been shown to improve quality of life and survival in patients with non-small cell lung cancer (N Engl J Med 2010 Aug 19;363(8):733), palliative chemotherapy in the last month of life has been associated with increased risk of intensive medical treatment and death in an intensive care unit (Ann Oncol 2011 Nov;22(11):2375, BMJ 2014 Mar 4;348:g1219). However, there remain many uncertainties with regard to quality of life outcomes in patients receiving chemotherapy near the end of life.
A recent prospective cohort study followed 621 patients with end-stage, progressive metastatic cancer after at least 1 chemotherapy regimen. All patients had a life expectancy ≤ 6 months based on physician estimation. The most common cancers in this study were lung, breast, colon, pancreatic and other gastrointestinal cancers, which together comprised approximately 70% of all cancers. During the study 384 patients died. The analysis included 312 patients (81.3%) who were not participating in clinical trials and who had complete data. Of these 312 patients, 50.6% received palliative chemotherapy at baseline and the distribution of Eastern Cooperative Oncology Group (ECOG) performance status (PS) scores included 39.1% with good performance (PS 1), 37.2% with moderate performance (PS 2), and 18.6% with poor performance (PS 3). Patients receiving chemotherapy were significantly younger (p < 0.001) and had better baseline performance status (p < 0.001). The patient’s quality of life during their last week of life was assessed through an interview at a median of 2.4 weeks after the patient’s death with the caregiver most knowledgeable about the patient’s care. Comparing chemotherapy use vs. nonuse, chemotherapy use was associated with a reduction in the quality of life near death for patients with a good baseline performance status (odds ratio 0.35, 95% CI 0.17-0.75). There was no association between chemotherapy use and quality of life near death for patients with moderate or low performance status, however. There was also no significant association between chemotherapy use and mortality.
For patients with poor ECOG performance, this study found no association between palliative chemotherapy and quality of life, in agreement with previous studies. Surprisingly, for patients with good ECOG performance, palliative chemotherapy was associated with a reduced quality of life near death. This is the population most likely to receive palliative chemotherapy and in whom it is thought chemotherapy may provide the greatest benefit. Palliative chemotherapy was also not associated with improvement in survival, but the study was underpowered to detect differences in this outcome. Overall, the results of this trial suggest that for all patients with end stage cancer and an estimated life expectancy of ≤ 6 months, palliative chemotherapy may negatively impact patient quality of life or at best, offer no benefit.
For more information, see the Management of advanced non-small cell lung cancer topic in DynaMed.