Chemotherapy Near the End of LifeFirst— and Third and Fourth (Line)—Do No Harm

Khoirul Anwar

Pembimbing :dr. Kartika W, Sp.PD KHOM

BookS Reading

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

Background

NEAR DEAD AGRESSIVE CHEMOTHERAPY ?

QUALITY OF LIFE

END STAGE CANCER

PALIATIVE CARE

“A GOOD DEATH”

NEAR THE END OF LIFE

PERSEPECTIVEPATIENT ?

PATIENT FAMILY ?POPULATION ?

PALIATIVE CARE

PERSEPECTIVEDOCTORS ?NURSES ?

CULTURERELIGION

SOCIALEDUCATION

Near Dead Chemotherapyto help them live LONGER

chemotherapy in metastatic cancerto help them live BETTER

NEAR THE END OF LIFEQUALITY

OF LIFE ?

Near dead chemotherapy• Mod / poor PS QOD

⬇• Good PS QOD not

improve

Near Dead ChemoTx QOL

Massarelli E et al, Lung Cancer. 2003;39(1):55-61.

Near Dead ChemoTx benefits?

late-line therapy is not effective for small cell lung cancer (NSCLC) treatment as having a 0% to 2%

response rate for third- and fourth-line use

Schnipper LE et al. ClinOncol. 2012;30(14):1715-1724

patients with good performance status were the ones most likely to receive chemotherapy near the

end of life

Prigerson HG et al. AMAOncol. doi:101001/jamaoncol.2015.2378.

palliative chemotherapy worsened QOD for patients with good performance status.

Why the oncologists still use systemic therapy so close to patient death ????

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

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.

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

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

Why the oncologists still use systemic therapy so close to patient death ????

NEAR DEAD AGRESSIVE CHEMOTHERAPY ?

“A GOOD DEATH”

NEAR THE END OF LIFE

PERSEPECTIVEPATIENT ?

PATIENT FAMILY ?POPULATION ?

PERSEPECTIVEDOCTORS ?NURSES ?

CULTURERELIGION

SOCIALEDUCATION

“A GOOD DEATH”

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

• being mentally aware• not being a burden to

others• being able to help

others• having funeral

arrangements planned• and spirituality

WESTERN“fighting against cancer.”• fighting against the

disease until one’s last moment

• believing that one used all available treatments

• living as long as possible

EASTERN

Steinhauser KE et al. 2000. JAMA 284: 2476–2482

Miyashita M et al. 2007. Ann Oncol 18:1090–1097

“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

• 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

Why the oncologists still use systemic therapy so close to patient death ????

ONCOLOGIST FACTORS PATIENT FACTORS

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 clearly about prognosis and are honest about the limitations of treatment

many patients feel immense pressure to continue treatment.

Patients with are encouraged by friends and family to keep fightingThe doctor 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

Why the oncologists still use systemic therapy so close to patient death ????

ONCOLOGIST FACTORS PATIENT FACTORS

GUIDELINE

to prohibit chemotherapy for allpatients 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 makegood 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