Study: Chemo doesn't help end-stage cancer patients

A new study finds that half of cancer patients received chemotherapy in their final months of life, even though the therapy – which can cause nausea, vomiting and other grueling side effects –  had no chance of curing them.

Doctors often prescribe chemo to people in the end stages of cancer in the hope that the drugs will shrink patients' tumors and make them feel better, said study co-author Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medical College in New York.

Her new research, however, found no evidence that chemo improved patients' quality of life. For the healthiest, least disabled patients, quality of life actually got worse after chemo, Prigerson said. The study of 312 patients, published Thursday in JAMA Oncology, included only people expected to live six months or less.

"People put a lot of stock in treatment and they tend to overestimate the odds that treatment will work," said Timothy Quill, a professor of medicine, psychiatry and medical humanities at the University of Rochester Medical Center, who wasn't involved in the new study. "There is a real potential for harm here and making quality of life worse."

That doesn't mean chemo has no benefit.

Chemo can cure many types of early cancer. Even when chemo can't cure people, it can often give them more time, said Thomas Smith, director of palliative medicine at Johns Hopkins Medical Institutions in Baltimore. When one chemo regimen fails, a different kind may still give people extra months of life.

But if cancer continues to spread after two or three chemo regimens, there's usually a "vanishingly small" chance that a fourth or fifth type will prolong someone's life, Smith said.

Still, many cancer specialists prescribe additional treatment in these cases because they assume "these patients have nothing to lose and may feel better," Prigerson said.

Her study overturns that assumption, Prigerson said. For people with end-stage cancer, "we didn't find any positive outcome to chemotherapy."

Those results suggest that doctors should consider changing their guidelines for care of cancer patients near the end of life, Prigerson said.

The default option for patients expected to live less than six months should be to withhold chemo, according to an editorial accompanying the study, written by Charles Blanke and Erik Fromme, physicians at Oregon Health and Science University.

Doctors should only prescribe chemo for these patients after talking to patients about their "prognosis, goals, fears and acceptable trade-offs," they wrote.

Many doctors never initiate these difficult conversations, which can be painful for everyone involved.

"We as oncologists don't want to give up on people, and patients don't want to be given up on," Smith said.

Recently, Smith said he had to be blunt with a family about their mother's condition. "I wish it were different," he told them. "But there isn't a chemotherapy that will make your mom live longer or better. I'm very afraid that if I give her chemotherapy in her current state, we will shorten her life, with no chance of benefit."

If doctors don't offer this sort of guidance, patients and their families need to ask, Quill said.

"People need to ask, 'How likely is this to work? How likely is this to make my quality of life better or worse?'" Quill said.

A growing number of hospitals now offer palliative care, which focuses on relieving symptoms and providing psychological, spiritual and practical support to patients and families, Smith said. Palliative care teams talk to patients about their wishes and how they want to use the time they have left.

Palliative care can include hospice services – typically given to people in the last six months of life –  but also can be provided as soon as patients as diagnosed with a life-limiting illness.

Four clinical trials have shown that providing palliative care helps patients live longer, perhaps because care teams pay close attention to patients' symptoms. Studies show that palliative care also reduces depression and anxiety.

About 80% of cancer patients want to know their prognosis, Smith said.

Yet in a study published last year in The Journal of Palliative Care Medicine, only 17% of people with incurable lung cancer realized that their survival would likely be less than two years. Another study found that only a fraction of patients with advanced lung cancer understood that chemo was unlikely to cure them.

When patients don't talk about the end of life, Smith said, "you lose so many opportunities for a family to say, 'My time is limited. Let's make the most of every day. Let's say, 'I love you.'"