BookS Reading

Chemotherapy Near the End of Life

First— and Third and Fourth (Line)—Do No Harm

Having a “good death” is one of the most important goals of palliative care..

Khoirul Anwar

Pembimbing :
dr. Kartika W, Sp.PD KHOM
 Background
END STAGE PALIATIVE QUALITY OF
PALIATIVE CARE
CANCER CARE LIFE

NEAR THE END

“A GOOD DEATH”
OF LIFE
PERSEPECTIVE
PATIENT ?
PATIENT FAMILY ?
POPULATION ? CULTURE NEAR DEAD AGRESSIVE
RELIGION CHEMOTHERAPY ?
PERSEPECTIVE SOCIAL
DOCTORS ? EDUCATION
NURSES ?
 Near Dead Chemotherapy
to help them live LONGER
chemotherapy in metastatic cancer
to help them live BETTER

NEAR THE END

QUALITY OF LIFE
OF LIFE ?
Near Dead ChemoTx  QOL

Near dead chemotherapy

• Mod / poor PS  QOD ⬇
• Good PS  QOD not
improve
 Near Dead ChemoTx  benefits?
late-line therapy is not effective for small cell lung
Massarelli E et al, Lung Cancer.
cancer (NSCLC) treatment as having a 0% to 2%
2003;39(1):55-61.
response rate for third- and fourth-line use

patients with good performance status were the

Schnipper LE et al. ClinOncol.
ones most likely to receive chemotherapy near the
2012;30(14):1715-1724
end of life

Prigerson HG et al. AMAOncol. palliative chemotherapy  worsened QOD for

doi:101001/jamaoncol.2015.2378. patients with good performance status.

Why the oncologists still use systemic therapy so close to patient death ????
 Near Dead ChemoTx  worldwide
A Norwegian study characterizing patients receiving palliative chemotherapy
• 3% ECOG 2
• 16% ECOG 3 and 4
• 10% received chemotherapy in the last 30 days of life
• Among those patients, 21% lung cancer; 15% colorectal; 13% prostate; and 9%,
breast cancer.

AnshushaugM et al. ActaOncol. 2015;54(3):395-402

Of the breast cancer patients

• 12% were receiving second-line therapy (associated with 3- to 6-month duration of
response)
• 19% third-line therapy (2 to 4 month duration of response)
• 21% third-line therapy or higher

Jones SE et al. J Clin Oncol. 2005;23(24):5542-5551.

Why the oncologists still use systemic therapy so close to patient death ????
 NEAR THE END
“A GOOD DEATH”
OF LIFE
PERSEPECTIVE
PATIENT ?
PATIENT FAMILY ?
POPULATION ? CULTURE NEAR DEAD AGRESSIVE
RELIGION CHEMOTHERAPY ?
PERSEPECTIVE SOCIAL
DOCTORS ? EDUCATION
NURSES ?
 “A GOOD DEATH”

Having a “good death” is one of the most important goals of palliative care..

WESTERN EASTERN
• being mentally aware “fighting against cancer.”
• not being a burden to • fighting against the
others disease until one’s last
• being able to help moment
others • believing that one used
• having funeral all available treatments
arrangements planned • living as long as possible
• and spirituality Miyashita M et al. 2007. Ann Oncol 18:1090–
1097
Steinhauser KE et al. 2000. JAMA 284: 2476–
2482
“A GOOD DEATH”
 “A GOOD DEATH”

• The good death components differed for patients and the general population
compared to oncologists and oncology nurses

• Patients favored “fighting against the disease until one’s last moments”; and patients
who emphasized maintaining hope and pleasure, unawareness of death and good
relationship with family favored fighting against cancer

• However, those who emphasized physical and psychological comfort preferred not to
fight
 Why the oncologists still use systemic therapy so close
to patient death ????

ONCOLOGIST FACTORS PATIENT FACTORS

• Can not precisely predict life
expectancies
 estimates of patient survival were
inaccurate approximately 80% of the
time (Christakis NA et al. 2000;320(7233):469-
472)
• It is hard to say no to chemotherapy 
make an oncologist feel they are
depriving the patient of all hope.
• FIGHTING AGAINTS CANCER
• Want systemic treatment until the bitter
end
 patients with incurable NSCLC would
desire chemotherapy, even in the
setting of severe toxi ceffects for a 1-
week gain in survival (Silvestri G et al.
1998; 17(7161): 771-775)
• Patient Hope

EDUCATION, COMMUNICATION and

NEGOTIATION ??
 EOL Consultation

 Early EOL discussions are prospectively associated with less aggressive care and greater
use of hospice at EOL.
 EOL Consultation

 Palliative Care (PC) consultation and a higher intensity of PC were associated with less
aggressive care near death in patients with advanced pancreatic cancer.
 Why the oncologists still use systemic therapy so close
to patient death ????

ONCOLOGIST FACTORS PATIENT FACTORS

EDUCATION, COMMUNICATION and

NEGOTIATION ??

Even when oncologists communicate many patients feel immense pressure

clearly about prognosis and are honest to continue treatment.
about the limitations of treatment
Patients with are encouraged by
The doctor feel the last 6 months of friends and family  to keep fighting
life are not best spent in an oncology
treatment unit or at home suffering
the toxic effects of largely ineffectual
therapies
 Why the oncologists still use systemic therapy so close
to patient death ????

ONCOLOGIST FACTORS PATIENT FACTORS

GUIDELINE
to prohibit chemotherapy for all
patients near death without irrefutable data defining
who might actually benefit, but if an oncologist
suspects the death of a patient in the next 6 months,
the default should be no active treatment.

Let us help patients with metastatic cancer make

good decisions at this sad stage.

Let us not contribute to the suffering that cancer, and

often associated therapy, brings, particularly at the end.
MATUR NUWUN