ESMO 2016: Researchers Identify Factors Associated With End-of-Life Chemotherapy Use
The rates of administering chemotherapy to patients with solid cancers within a month of succumbing to their disease remain high, which calls for a paradigm shift to consider initiating palliative care at an earlier stage and formulating clear guidelines for end-of-life care, according to findings of a large audit presented by Rochigneux et al at the 2016 European Society for Medical Oncology (ESMO) Congress in Copenhagen (Abstract 1300O).
Chemotherapy is often administered near the end of life for solid cancer patients with the intent to ease symptoms, but is usually ineffective and toxic, according to lead author Phillipe Rochigneux, MD, of the Department of Medical Oncology at the Institut Paoli-Calmettes in Marseille, France. Dr. Rochigneux presented findings on behalf of collegues from a review of the data concerning the use of chemotherapy at the end of life throughout France and the factors associated with its use.
The investigators designed a nationwide, register-based study that included all patients hospitalized in France between 2010 and 2013 who were aged 20 years and older and had died of metastatic solid tumors. They used multivariate analyses to identify patients, tumor, and the facility level characteristics associated with chemotherapy use. Specific subanalyses were also computed to investigate the role of the putative chemosensitivity of the tumor, as defined by a response rate of the tumor to standard first-line chemotherapy > 30% (literature data).
Higher Rates of End-of-Life Chemotherapy in Hospitals Without Palliative Care Units
Data regarding 279,846 metastatic solid cancers in patients at the end of their lives were included in the register.
The rates of chemotherapy administration near the end of life were 39.1% during the last 3 months, 19.5% during the last month, and 11.3% within the final 2 weeks. During their last month of life, 6.6% of patients started or resumed a chemotherapy regimen.
Patient characteristics associated by multivariate analysis with lower rates of chemotherapy included female sex (odds ratio [OR] = 0.96; 95% confidence interval [CI] = 0.93–0.98); older age (OR = 0.70; 95% CI = 0.69–0.71 for each 10-year increase); and a higher number of chronic comorbidities (OR = 0.83; 95% CI = 0.82–0.84).
Patients were more likely to receive chemotherapy during the last month of life if their tumors displayed chemosensitivity to standard first-line chemotherapy (OR = 1.21; 95% CI = 1.18–1.25). Another factor independently associated with end-of-life chemotherapy was patients having cancer types for which major therapeutic innovations occurred from 2005 to 2010 (OR = 1.17; 95% CI = 1.14–1.20).
End-stage chemotherapy rates were also higher in patients dying in a for-profit hospital compared with university hospitals (OR = 1.40; 95% CI = 1.34–1.45) and in patients in comprehensive cancer centers (OR = 1.43; 95% CI = 1.36–1.50). Higher-than-average rates of chemotherapy were reportedly administered near the end of life in high-volume cancer centers and in hospitals lacking palliative care units (OR = 1.21; 95% CI = 1.18–1.24).
Ways to Move Away From This Model
Stein Kaasa, MD, PhD, Professor of Palliative Medicine at the Institute of Cancer Research and Molecular Medicine at the Norwegian University of Science and Technology, Trondheim, discussed the study findings. Dr. Kaasa pointed out that patients want to live as long and as well as possible. However, he questioned whether that should include access to chemotherapy when close to death. He also wondered, if the goal is to reduce the use of chemotherapy close to death, how to do it? He suggested it is best to establish a relationship with patients that is “more than only tumor-focused” (addressing emotional and family issues, considering the use of advanced directives), perform systematic symptom and function assessments, and communicate the prognostic information to the patients.
Conclusions
Chemotherapy rates near the end of life remain high in patients with metastatic solid cancers. These rates are especially high in young patients being treated in high-volume centers that lack a palliative care unit.
There is an urgent need to decrease the aggressiveness of end-of-life treatments by making and implementing clear guidelines for end-of-life care, to initiate palliative care earlier on, and to reinforce supportive care training for oncologists and other cancer professionals.
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®.
