The aggressiveness of cancer care near the end of life has emerged as both a quality and cost issue of critical importance.1–4 The American Society of Clinical Oncology recommends the avoidance of chemotherapy at this juncture due not only to the absence of evidence supporting its value, but also due to its association with heightened toxicity, compromised quality of life, the likelihood of dying in the acute care setting, and less frequent use of hospice care.5 Hence the prominence of chemotherapy’s use peri-death, is now considered an indication of questionable quality within oncology programs.6, 7
A recent nationwide French review of nearly 300,000 hospitalized patients who died from metastatic solid tumors, aimed to identify factors associated with chemotherapy’s use near the end of life.8 Nearly 40% of patients received chemotherapy during the final 3 months of life, approximately 20% during the last month, 11% during the last 2 weeks, and 7% during the last week before death. Male gender, younger age, and a low number of comorbidities were linked with an increased likelihood of receiving chemotherapy within the last 4 weeks of life. Young adult patients treated in comprehensive cancer centers or in high-volume treatment facilities without palliative care units were most likely to receive chemotherapy during this time frame.
Findings posited some interesting considerations that have relevance to cancer care within many developed western nations. The “therapeutic illusion” that currently exists in many patients, families, and physicians, is rooted in the belief that the potential effectiveness of systemic cancer therapy may prompt over-realistic expectations as death approaches which results in the prescribing of unnecessary treatments with potentially harmful effects.9–11 Additionally, when the integration of multidisciplinary palliative care into cancer care is absent, the aggressiveness of medical interventions near the end of life may likely escalate.
This study documented that one in five hospitalized cancer patients who ultimately die from their malignancy receive chemotherapy with the last month of their life. The authors noted that “Our findings are symptomatic of an increasingly pressing societal demand for the medicalization of the final years and months of life.” (p. 813).8
As oncology nurses, we can share the evidence of the absence of treatment efficacy when decision-making is deliberated. We also have an obligation to lobby and advocate for enhanced communication between physicians, patients, and families around goals of care planning at life’s closure. As central figures within the lives of cancer patients and families at this time of heightened vulnerability, it is the right thing for us to do.
Earle CC, Neville BA, Landrum MB, et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004 Jan 15;22(2):315-21.
Martoni AA, Tanneberger S, Multri V. Cancer chemotherapy near the end of life: The time has come to set guidelines for its appropriate use. Tumori. 2007 Sep-Oct;93(5):417-22.
Garrido MM, Prigerson HG, Bao Y, Maciejewski PK. Chemotherapy use in the months before death and estimated costs of care in the last week of life. J Pain Symptom Manage. 2016 May;51(5):875-881.
Kao S, Shafiq J, Vardy J, Adams D. Use of chemotherapy at end of life in oncology patients. Ann Oncol. 2009 Sep;20(9):1555-9.
Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. J Clin Oncol. 2012 May 10;30(14):1715-24.
Earle CC, Landrum MB, Souza JM, et al. Aggressiveness of cancer care near the end of life: Is it a quality-of-care issue? J Clin Oncol. 2008 Aug 10;26(23):3860-6.
Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol, 1(6): 778-784.
Rochigneux P, Raoul JL, Beaussant Y. Use of chemotherapy near the end of life: What factors matter? Ann Oncol. 2017 Apr 1;28(4):809-817.
Glare P, Virik K, Jones M, et al. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ. 2003 Jul 26;327(7408):195-8.
Chen CH, Kuo SC, Tang ST. Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis. Palliat Med. 2017 May;31(5):406-418.
Casarett D. The science of choosing wisely – Overcoming the therapeutic illusion. N Engl J Med. 2016 Mar 31;374(13):1203-5.
FDA Approves Onivyde for Advanced Pancreatic Cancer Marijke Vroomen Durning, RN, 10/27/2015 3 On October 22, 2015, the US Food and Drug Administration (FDA) approved Onivyde (irinotecan liposome injection, Merrimack Pharmaceuticals, Inc.), in combination with fluorouracil ...