The question of when to stop treatment for people with metastatic disease that continues to grow despite all efforts is a gut-wrenching choice. It’s very hard to make the transition from fighting the disease to beginning to think about how to prepare for the end of life. The challenge is extremely painful for both the person diagnosed with cancer and her/his loved ones.
In many cases, people with end-stage metastatic cancer are offered chemotherapy to ease pain and improve their quality of life. When chemotherapy is given for these reasons, it’s called palliative chemotherapy. Still, not much research has looked at whether palliative chemotherapy for end-stage disease actually does improve quality of life.
A study suggests that few people benefit from end-of-life chemotherapy and many people have worse quality of life after receiving it.
The study was published online on July 23, 2015 by JAMA Oncology. Read the abstract of “Chemotherapy Use, Performance Status, and Quality of Life at the End of Life.”
Guidelines from the American Society of Clinical Oncology (ASCO) recommend that palliative chemotherapy not be given to people diagnosed with growing metastatic disease who are very sick and bedridden and who can’t take care of their own daily needs. For people diagnosed with growing metastatic cancer who are in relatively good health and self-sufficient, ASCO guidelines recommend trying palliative chemotherapy to ease pain or help the person live longer.
ASCO is a national organization of oncologists and other cancer care providers. ASCO guidelines give doctors recommendations for treatments that are supported by much credible research and experience.
In this study, the researchers followed 312 people diagnosed with end-stage metastatic cancer between 2002 and 2008 who were told they had 6 months or less to live:
- about 55% of the people in the study were men and 45% were women
- 61.5% were white, 20.5% were black, and 16.7% were Latino
The people had been diagnosed with a number of different metastatic cancers:
- 23.1% had lung cancer
- 13.5% had breast cancer
- 12.8% had colon cancer
- 7.4% had pancreatic cancer
- 12.2% had other gastrointestinal cancer
- 31.1% had another type of cancer
The people in the study were followed until they died.
At the beginning of the study, the researchers asked the people in the study about their quality of life as well as their level of well-being, both physically and psychologically. The researchers also asked the caregiver most familiar with the person’s well-being to do the same assessment. After a person died, the researchers asked the caregiver to rate the person’s quality of life in the last week of life. The caregivers’ assessments were considered accurate because their assessments matched the people’s self-assessments when the study started.
About half the people in the study opted for palliative chemotherapy, including 28 of 42 people diagnosed with metastatic breast cancer.
For people who were the sickest and had a lower quality of life when the study started, the caregiver rating of their last week of life was about the same whether or not the people had received palliative chemotherapy. So the end-of-life chemotherapy didn’t seem to improve quality of life for these people.
For people who were in relatively good health and had better quality of life when the study started, more than half (56%) had worse quality of life in their final week of life after receiving palliative chemotherapy. To compare, 31% of people who had better quality of life when the study started who didn’t receive palliative chemotherapy had worse quality of life in their final week of life. So palliative chemotherapy seemed to decrease quality of life for people who were in relatively good health at the beginning of the study.
The researchers said that it was likely the side effects of chemotherapy, including nausea, diarrhea, and fatigue, that decreased quality of life for the relatively healthy people.
There was no difference in survival between the people who got palliative chemotherapy and people who didn’t.
In a companion editorial, Charles D. Blanke, M.D., FACP, FASCO, and Erik K. Fromme, M.D., MCR, FAAHPM, both of Oregon Health and Science University, wrote, “In reality, only two major reasons exist for administering chemotherapy to most patients with metastatic cancer: to help them live longer and/or to help them live better. In exchange for treatment-related toxic effects (as well as substantial time, expense, and inconvenience), chemotherapy can prolong survival for patients with a variety of -- though not all -- solid tumors. Chemotherapy may also improve quality of life for patients by reducing symptoms caused by a malignancy. In this issue of JAMA Oncology, Prigerson and colleagues report some troubling trial results: chemotherapy administered to patients with cancer near the end of life achieved neither goal.
"Even when oncologists communicate clearly about prognosis and are honest about the limitations of treatment, many patients feel immense pressure to continue treatment," Blanke and Fromme continued. "Patients with end-stage cancer are encouraged by friends and family to keep fighting, but the battle analogy itself can portray the dying patient as a loser and should be discouraged. Costs aside, we feel the last 6 months of life are not best spent in an oncology treatment unit or at home suffering the toxic effects of largely ineffectual therapies for the majority of patients."
It’s important to know that all the people in the study were diagnosed between 2002 and 2008, before some newer cancer chemotherapy medicines with fewer side effects were developed.
“Doctors have been learning who not to treat, and I think this captures what we did 10 years ago,” said Thomas Gribbin, M.D., an oncologist in Michigan, in an interview in the New York Times. “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.”
Treatment decisions for end-stage cancer are extremely personal and individualized. What is right for one person may be completely wrong for another person. It’s important to talk to your doctor, your family, and other loved ones. There are no hard and fast rules. Some people prefer to receive treatment up until the last day of their lives, while others will stop and prefer to spend the last weeks or months of their lives with their families, with their pain and other symptoms controlled, but without having to deal with being in treatment anymore.
By keeping the lines of communication open with your doctors, you can explain what you want and your doctors can help you achieve it.
For more information on living with metastatic breast cancer, including taking breaks from treatment and stopping treatment, visit the Breastcancer.org Recurrent and Metastatic Breast Cancer pages.