Health

Aggressive Therapy at End of Life Common in Cancer

Use of aggressive therapy among cancer patients who died within a month of diagnosis varied widely, but approached 30% for certain types of cancer and interventions, a large retrospective analysis showed.

The data showed that 28.3% of patients with metastatic colorectal cancer had surgery in the month before they died, and 18.7% of patients with advanced lung cancer had radiation therapy. Additionally, 11% of patients with advanced lung and breast cancers received chemotherapy in the last month of life, according to Helmneh M. Sineshaw, MD, MPH, of the American Cancer Society in Atlanta, and colleagues.

Although use of some aggressive therapies declined over the study period of 2004-2014, many patients with “imminently fatal” cancers received treatment that likely provided no benefit, they reported online in JNCI Cancer Spectrum.

“Hospice care and palliation are options that should be discussed for these types of patients,” Sineshaw told MedPage Today. “We found that many patients received chemotherapy, hormonal therapy, surgery, radiation therapy. This was not for palliation. These patients were receiving the treatment for prolonging their lives.”

Derived from a large national registry, the data for the study did not provide insight into specific factors that might have influenced the decision to pursue aggressive treatment.

“Many factors play into this,” Sineshaw said. “The physician might have provided highly optimistic information about the patient’s survival. Patients may be highly optimistic about their condition. The family also may have a role in discussions about cost and toxicity and other factors affecting survival but disregarding quality of life, high quality of care, hospice care, palliative care.”

Future studies should focus on distinguishing patients who might benefit from aggressive treatment from those who would be better served by palliation and hospice care, he added.

The study is the latest in a growing number of investigations into the quantity and intensity of care that patients receive at or near the end of life. Recently, two separate studies — one from Sweden, the other from France — showed that many patients with terminal illness continued to receive treatments with questionable benefits and many received aggressive, invasive therapies during the last 30 days of life.

Sineshaw and colleagues reported findings from an analysis of the National Cancer Database for the years 2004-2014. They limited the data query to patients who died within 1 month after diagnosis of one of four types of metastatic cancer: pancreatic, colorectal, lung, and breast. They focused on use of chemotherapy, hormonal therapy, radiation therapy, and surgery.

Of the 100,848 patients included in the analysis, 66.5% had lung cancer, 18% had pancreatic cancer, 12% had colorectal cancer, and 3.6% had female breast cancer. Most (77%) of the patients were white, 44% were ages ≥75, and 60% received treatment at facilities with a high volume of de novo metastatic cancer care.

Overall, 27.4% of the patients received one of the four cancer-directed treatments in the study focus. The total included 37.2% of patients with colorectal cancer, 34.9% of patients with breast cancer, 29% of those with lung cancer, and 12.5% of those with pancreatic cancer.

Use of the different types of cancer-directed therapy varied by the type of cancer, with highs and lows of:

  • Surgery to primary tumor: Colorectal, 28.3%; pancreatic 0.4%
  • Chemotherapy: Lung and breast, 11.3%; colorectal, 5.8%
  • Radiotherapy : Lung, 18.7%; pancreatic, 1.3%
  • Hormonal therapy: HR-positive breast cancer, 23.9%

The authors found that 27% of patients with small-cell lung cancer received chemotherapy. From 2010-2014, 33% of women with HR-negative/HER2-positive breast cancer received chemotherapy. Surgery for distant metastases was uncommon, occurring most often in patients with colorectal cancer (4.6%).

Over the study period, rates of use declined significantly (P<0.01) for primary surgery for colorectal and breast cancer, chemotherapy for lung, breast, and pancreatic cancer, and radiation therapy for lung and breast cancer. Sineshaw said the finding suggested that more oncologists have reservations about using aggressive treatment at the end of life.

Several factors influenced the likelihood that a patient would receive aggressive treatment, but the impact varied by type of treatment and cancer. Older age (≥75 vs 18-39) was associated with less use of radiotherapy and chemotherapy for lung cancer and for use of chemotherapy for breast cancer. A higher comorbidity score lowered the odds for chemotherapy in patients with pancreatic cancer and radiotherapy for lung cancer.

Uninsured patients had lower odds of primary surgery for colorectal cancer, radiotherapy for lung cancer, and chemotherapy for all four cancers. The analysis revealed multiple variations in the types of care, according to the treating facility (community cancer center, comprehensive community cancer center, NCI-designated cancer center, academic medical center).

The study was supported by the American Cancer Society and the National Cancer Institute.

Sineshaw disclosed no relevant relationships with industry. Co-authors disclosed relevant relationships with Foundation Medicine, Pfizer, Eli Lilly, the Association of Community Cancer Centers, and Merck.

2019-04-15T19:00:00-0400


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