Identifying Processes That Lead to Discontinuation of Chemotherapy for Patients With NSCLC at End of Life
According to a recent study by Perl et al published in the Journal of Oncology Practice, the administration of chemotherapy near death is recognized by patients, their families, and oncologists as “aggressive and poor-quality care.” Despite this, rates of end-of-life chemotherapy have been increasing over the past 10 years, with 5% to 22% of all patients with advanced cancer receiving chemotherapy within 2 weeks of death.
To identify the processes leading to discontinuation of chemotherapy for patients with metastatic non–small-cell lung cancer (NSCLC) at the end of life, the researchers reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic NSCLC who participated in a trial of early palliative care. The mean age of the patients was 64 years old and the median number of lines of chemotherapy was 2 to 2.5.
One-Quarter Lack Documented Decision
A total of 144 patients died, 81 who had received intravenous (IV) chemotherapy and 48 who had received oral chemotherapies as their final regimen, but 40 of those 48 patients (83.3%) switched from IV to oral delivery as their final regimen, “sometimes concurrent with or even after hospice referral,” the investigators noted. The median time between transitioning from IV to oral chemotherapy was 134.5 days. Nine patients did not receive chemotherapy, and six were excluded due to transfer of care or lack of end-of-life data.
The median time between the last IV chemotherapy infusion and death was 55 days. “However, almost one quarter of patients in the sample had no documented decision to discontinue IV chemotherapy altogether,” the researchers wrote. For patients with documented final decisions, the median time from the decision to the patient’s death was only 20 days.
Five Processes for Stopping Chemotherapy
The authors identified five processes for stopping IV chemotherapy. These processes are: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). Notes for patients in the no decision category “suggest that they were unexpected, with some oncologists indicating that patients died a ‘sudden death.’ Nonetheless, several notes raise the possibility that oncologists may not have recognized that patients were close to death,” the authors wrote.
“The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later,” the researchers reported. The processes “seemed to vary based on how confident the oncologist might be in his or her assessment of the time course of a patient’s disease,” the authors added. “Oncologists have been shown to overestimate the survival of their terminally ill patients, which could lead to overconfidence in administering chemotherapy to a patient close to death.”
Date Is Not a Proxy for Decision
The “study demonstrates that the date of last chemotherapy treatment is not a proxy for when a decision to stop cancer treatment is made,” the investigators observed. “In this sample of patients with metastatic NSCLC, < 20% had evidence of a definitive decision to stop chemotherapy at the time their chemotherapy was discontinued. For the majority of patients, a substantial amount of time followed the last IV chemotherapy treatment before a final decision to stop chemotherapy was made.”
While ASCO “recommends stopping chemotherapy when evidence-based therapies show no benefit and the clinical value of further treatment lacks supporting evidence,” in this study “discontinuation of chemotherapy seemed to occur more often in response to failures rather than futility or lack of benefit,” the authors noted. “Patients typically continued to receive chemotherapy until marked physical or functional deterioration requiring a disruption, often for more immediate medical treatment.”
The authors concluded that “chemotherapy discontinuation should not just be considered a date before death; it is a process. Differentiating the processes of discontinuing chemotherapy seems to be meaningful, because these processes occur at significantly different time points before death and may affect subsequent [end-of-life] care, such as hospice referral, days in hospice, and death in the hospital. Understanding these processes has the potential to reduce the administration of chemotherapy at [end of life] by identifying not only practices with better outcomes but also factors that trigger earlier discontinuation.”
William F. Pirl, MD, MPH, of Massachusetts General Hospital, is the corresponding author for the Journal of Oncology Practice article.
The study was supported by the Radcliffe Institute for Advanced Studies, Harvard University, Conquer Cancer Foundation, and the National Cancer Institute.
For full disclosures of the study authors, visit jop.ascopubs.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
