VCU Massey Cancer Center Researchers Publish Perspectives on the Role of Chemotherapy at the End of Life

By Andrea Butler
Massey Cancer Center

Physician-researchers from the Virginia Commonwealth University Massey Cancer Center – home to one of the nation's leading cancer palliative care programs -- published a case study in today's issue of the Journal of the American Medical Association (JAMA) exploring the role of chemotherapy given in the last phases of life to cancer patients in the United States.

The authors explore why and how medical professionals should consider administering less chemotherapy at the end of life. Less chemotherapy would allow for better quality of life and easier transitions toward death for those whose illness is terminal. In addition, they provide information for patients to support their decision-making efforts.

The authors, Thomas J. Smith, M.D., and Sarah E. Harrington, M.D., serve respectively as medical director and attending physician of the VCU Massey Cancer Center's Thomas Palliative Care Program. Their award-winning, 11-bed inpatient palliative care unit has served as a model of quality care and training site for more than 75 other institutions.

About 15 percent to 20 percent of cancer patients nationwide with incurable cancers receive chemotherapy within 14 days of their death. At that stage, when the disease has progressed and patients are often failing, the chemotherapy has virtually no chance of helping.

Taking several other factors into account, chemotherapy toward the end of life may not be the best solution for many incurable patients. These factors include:

• Chemotherapy may have negative side effects, compromising the patients' sense of well-being

• People in hospice not receiving chemotherapy live longer

• Chemotherapy prevents patients from going into hospice

• One in three families is bankrupted by serious illness

• Patients receiving chemotherapy are likely to miss opportunities for spiritual growth, quality family time, travel, financial transitions and to pass on a "life review" for future generations.

The authors show that chemotherapy is given near the end of life in the United States more than in other countries. The contributing factors include:

• A lack of honest information about prognosis

• Hype from drug companies and national research organizations

• People not believing their doctors or having a different perspective

• Doctors and patients wanting to avoid frank discussion about the issue

• Doctors in the United States are paid to prescribe chemotherapy; they are not paid to counsel patients and help them prepare for a "good death."

"As doctors we are taught to save lives, and much of our training and practice is geared toward that effort," said Smith. "Patients and their families want and need more information to transition toward the best death possible. This article provides several helpful sections to identify the appropriate goals of chemotherapy, to transition to palliative or hospice care and to discuss prognoses in clear and effective manners with patients."

The solutions Smith and Harrington present to the medical profession include:

• More honest communication from the beginning with patients

• Bring up hospice

• Ask people what they want to know, and tell them.

Helpful Information for Patients

Cancer patients and family members seeking information to support decision-making for chemotherapy should visit the patient page accompanying the JAMA article at the Patient Page. It includes information on assessing their ability to benefit from more chemotherapy, and questions to ask their oncologist regarding their treatment and prognosis.

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Note: Facts and figures cited in the JAMA article are based on published findings of the known effects of standard chemotherapy. Some patients with poor prognosis and some slim hope may benefit from an early phase investigational therapy, or they may want to help in the development of that therapy regardless of whether it benefits them. In these cases, the cost of the drugs is not borne by the patient. This does not apply to patients already in hospice.