Chemotherapy is a two-edged sword. As an oncology trainee I’ve seen a few patients die solely because of it. And yet aggressive treatment is sometimes necessary to save a life; in the right settings it often succeeds. Patients with Hodgkins’ disease, testicular cancer, acute leukemias, and early stage colon, lung, or breast cancers, among others, are often cured because of chemotherapy and other aggressive treatments. Like any useful tool though, it must be properly applied in order to be effective and avoid harm. You wouldn’t use a screwdriver to drive a nail; similarly, chemotherapy shouldn’t be given to all patients in all situations, nor should it be a substitute for good discussions about goals of care and the likelihood of deriving benefit.
Yesterday’s cancer SIG presentation cut to the core of many issues that create tension between oncologists and palliative care clinicians. Most of us have probably seen difficult situations involving chemotherapy; it can be very upsetting! We tend to point the finger at oncologists when things go wrong, but we must recognize their unique perspective. To paraphrase one of today’s presenters, “Sometimes I can give a patient 5 different rounds of chemotherapy over 7 years and see them respond well each time.” In other words, chemo often really helps patients, even when its intent is palliative. I promise, we’re not monsters….oncologists are people too! 🙂
Data support the use of chemotherapy in a number of advanced disease settings, even many solid tumors. Yes, chemotherapy can and should be part of good palliation in many settings. There are significant symptom benefits, QOL improvements, and survival benefits to be had in cases of lung, breast, colon, and prostate cancer; many other solid tumors respond to chemotherapy as well. Of course, the devil is in the details. An emerging quality indicator in oncology practice is the proportion of patients receiving chemotherapy in the last 2 weeks of life. Too many patients are receiving chemo just before death.
Here’s the conundrum: we know chemotherapy can be beneficial, but only in certain settings. Unfortunately we’re not very good at predicting how well a particular patient will tolerate treatment, nor how well their tumor(s) will respond. How should we proceed?
The SIG speakers recommend following a framework: First, look to published guidelines like those from the NCCN, which tell us when chemotherapy is no longer recommended (link). If treatment is pursued, it must be done with full informed consent regarding its palliative intent. Treatment must be viewed as a time-limited trial, with specific criteria for measuring response and planned discontinuation if none is seen. Transitions to hospice should be discussed early, at the first signs of decline in function. And the palliative care team should be involved! As Dr. Smith pointed out, recent data on early palliative care in advanced lung cancer shows a resultant reduction in chemotherapy usage in the last 60 days of life. We still don’t really know how this works, but it works, and it doesn’t impair survival.
Going forward, palliative care will become more integrated into comprehensive cancer care, as per recent recommendations (link). This requires palliative care clinicians to better understand the role of chemotherapy as part of good palliative care for many cancer patients. Let’s be constructive, and increasingly work side-by-side with our oncology colleagues in caring for patients with incurable cancer. Hug an oncologist today! 🙂Thomas W. LeBlanc, MD, MA Fellow, Medical Oncology and Palliative Medicine Duke University