Posts tagged oncology

Chemo in the last 2 weeks of life

Chemotherapy is a two-edged sword. As an oncology trainee I’ve seen a few patients die solely because of it. And yet aggressive treatment is sometimes necessary to save a life; in the right settings it often succeeds. Patients with Hodgkins’ disease, testicular cancer, acute leukemias, and early stage colon, lung, or breast cancers, among others, are often cured because of chemotherapy and other aggressive treatments. Like any useful tool though, it must be properly applied in order to be effective and avoid harm. You wouldn’t use a screwdriver to drive a nail; similarly, chemotherapy shouldn’t be given to all patients in all situations, nor should it be a substitute for good discussions about goals of care and the likelihood of deriving benefit.

Yesterday’s cancer SIG presentation cut to the core of many issues that create tension between oncologists and palliative care clinicians. Most of us have probably seen difficult situations involving chemotherapy; it can be very upsetting! We tend to point the finger at oncologists when things go wrong, but we must recognize their unique perspective. To paraphrase one of today’s presenters, “Sometimes I can give a patient 5 different rounds of chemotherapy over 7 years and see them respond well each time.” In other words, chemo often really helps patients, even when its intent is palliative. I promise, we’re not monsters….oncologists are people too! :)

Data support the use of chemotherapy in a number of advanced disease settings, even many solid tumors. Yes, chemotherapy can and should be part of good palliation in many settings. There are significant symptom benefits, QOL improvements, and survival benefits to be had in cases of lung, breast, colon, and prostate cancer; many other solid tumors respond to chemotherapy as well. Of course, the devil is in the details. An emerging quality indicator in oncology practice is the proportion of patients receiving chemotherapy in the last 2 weeks of life. Too many patients are receiving chemo just before death.

Here’s the conundrum: we know chemotherapy can be beneficial, but only in certain settings. Unfortunately we’re not very good at predicting how well a particular patient will tolerate treatment, nor how well their tumor(s) will respond. How should we proceed?

The SIG speakers recommend following a framework: First, look to published guidelines like those from the NCCN, which tell us when chemotherapy is no longer recommended (link). If treatment is pursued, it must be done with full informed consent regarding its palliative intent. Treatment must be viewed as a time-limited trial, with specific criteria for measuring response and planned discontinuation if none is seen. Transitions to hospice should be discussed early, at the first signs of decline in function. And the palliative care team should be involved! As Dr. Smith pointed out, recent data on early palliative care in advanced lung cancer shows a resultant reduction in chemotherapy usage in the last 60 days of life. We still don’t really know how this works, but it works, and it doesn’t impair survival.

Going forward, palliative care will become more integrated into comprehensive cancer care, as per recent recommendations (link). This requires palliative care clinicians to better understand the role of chemotherapy as part of good palliative care for many cancer patients. Let’s be constructive, and increasingly work side-by-side with our oncology colleagues in caring for patients with incurable cancer. Hug an oncologist today! :)

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

Palliative Care for Cancer Patients in Treatment

by Porter Storey, MD, AAHPM Executive Vice President

Palliative care teams should be consulted more often for cancer patients in active treatment.

I know, I am “preaching to the choir” on this blog, but it may be important how we explain this to our various “stakeholders.”

The Public – Palliative care can help align patient wishes with their treatments and make sure patients and families are comfortable and supported.

Patients – Palliative care can help with symptom management, care coordination, psychosocial support so that you can continue your treatment and continue to do so after it is completed.

Hospice Programs – Palliative care can provide support before they qualify for hospice and refer patients to hospices sooner, for longer lengths of stay.

Payors and Program Administrators – Palliative care consultations can reduce costs and improve quality for the sickest (and most expensive) patients we care for. It can reduce hospital readmissions and save thousands of dollars per hospitalized patients (for the latest of many articles see Nelson C, et al. Inpatient Palliative Care Consults and the Probability of Hospital Readmission. Permanente J. 2011, 15(2):48-51.)

Referring Oncologists – Palliative care can act as an extension of the oncology care team so oncologists can focus on giving treatment. And as Tom Smith and Bruce Hilner argue in the May 26 NEJM, “bend the cost curve” so that we can afford to offer expensive new treatments to patients who can benefit from them (N Engl J Med 2011; 364:2060-2065).

Let’s not apply the wrong argument to the wrong class of stakeholders.

What do we say to the politicians?

Join the discussion when AAHPM offers the webinar “Changing the Mindset: Integrating Palliative Care into Cancer Treatment” lead by Tom Smith on Tuesday July 14 at 3pm ET.