Palliative chemotherapy: Historical perspective, applications, and controversies

Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan

Background

Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.

Methods

All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.

Results

During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20-2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38-3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48-6.38, p = 0.0027). Fewer patients in the "no referral" group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).

Conclusion

Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.

Identification of Patients with Recurrent Epithelial Ovarian Cancer Who Will Benefit from More Than Three Lines of Chemotherapy

Purpose

This study aimed to identify patients who would benefit from third and subsequent lines of chemotherapy in recurrent epithelial ovarian cancer (EOC).

Materials and Methods

Recurrent EOC patients who received third, fourth, or fifth-line palliative chemotherapy were retrospectively analyzed. Patients’ survival outcomes were assessed according to chemotherapy lines. Based on the best objective response, patients were divided into good-response (stable disease or better) and poor response (progressive disease or those who died before response assessment) groups. Survival outcomes were compared between the two groups, and factors associated with chemotherapy responses were investigated.

Results

A total of 189 patients were evaluated. Ninety-four and 95 patients were identified as good and poor response group respectively, during the study period of 2008 to 2021. The poor response group showed significantly worse progression-free survival (median, 2.1 months vs. 9.7 months; p < 0.001) and overall survival (median, 5.0 months vs. 22.9 months; p < 0.001) compared with the good response group. In multivariate analysis adjusting for clinicopathologic factors, short treatment-free interval (TFI) (hazard ratio [HR], 5.557; 95% confidence interval [CI], 2.403 to 12.850), platinum-resistant EOC (HR, 2.367; 95% CI, 1.017 to 5.510), and non-serous/endometrioid histologic type (HR, 5.045; 95% CI, 1.152 to 22.088) were identified as independent risk factors for poor response. There was no difference in serious adverse events between good and poor response groups (p=0.167).

Conclusion

Third and subsequent lines of chemotherapy could be carefully considered for palliative purposes in recurrent EOC patients with serous or endometrioid histology, initial platinum sensitivity, and long TFIs from the previous chemotherapy regimen.

Microfibril associated protein 4 (MFAP4) is a carrier of the tumor associated carbohydrate sialyl-Lewis x (sLex) in pancreatic adenocarcinoma

Late diagnosis of pancreatic ductal adenocarcinoma (PDA) is one of the reasons of its low 5-year survival rate and it is due to its unspecific symptoms during the first stages of the disease and the lack of reliable serological markers. Since PDA shows an altered glycan expression, here we have focused on finding novel potential biomarkers, namely glycoproteins that express the tumor associated carbohydrate structure sialyl-Lewis x (sLe^x), which is described in PDA. Through a glycoproteomic approach, we have analyzed target proteins containing sLe^x from PDA tissues by 2DE and immunodetection techniques, and have identified by mass spectrometry the protein MFAP4 as a carrier of sLe^x in PDA. MFAP4 showed a higher expression in PDA tissues compared with pancreatic control tissues. In addition, the colocalization of sLe^x over MFAP4 was found only in PDA and not in control pancreatic tissues. The analysis of MFAP4 expression in PDA cell lines and their secretome, in combination with immunohistochemistry of pancreatic tissues, revealed that MFAP4 was not produced by PDA cells, but it was found in the pancreatic extracellular matrix. The specificity of MFAP4 glycoform containing sLe^x in PDA tissues shows its relevance as a potential PDA biomarker. SIGNIFICANCE: Despite advances in the field of cancer research, pancreatic ductal adenocarcinoma (PDA) lacks of a specific and sensitive biomarker for its early detection, when curative resection is still possible before metastases arise. Thus, efforts to discover new PDA biomarkers represent the first line in the fight against the increase of its incidence reported in recent years. Glycan alterations on glycoconjugates, such as glycoproteins have emerged as a rich source for the identification of novel cancer markers. In the present work, we aimed to shed light on novel biomarkers based on altered glycosylation in PDA, in particular those glycoproteins of PDA tissues carrying the tumor carbohydrate antigen sialyl-Lewis x (sLe^x). Through a glycoproteomic approach, we have shown that the glycoprotein MFAP4 carries sLe^x in PDA tissues and not in control pancreatic tissues. MFAP4 is found in the extracellular matrix in PDA and although its role in cancer progression is unclear, its sLe^x glycoform could be a potential biomarker in pancreatic ductal adenocarcinoma.

Impact of palliative chemotherapy and best supportive care on overall survival and length of hospitalization in patients with incurable Cancer: a 4-year single institution experience in Japan

BACKGROUND

This study aimed to analyze the determinants of patients' choice between palliative chemotherapy and best supportive care (BSC) and to investigate how this choice affects overall survival (OS) and length of hospitalization according to Eastern Cooperative Oncology Group (ECOG) performance status (PS).

METHODS

An oncologist explained the palliative chemotherapy and BSC options to 129 patients with incurable cancer during their first consultation. Data on the ECOG PS, treatment decision, OS, and the length of hospitalization were retrospectively collected over 4 years.

RESULTS

Patients with an ECOG PS of 0-2 chose palliative chemotherapy more often than those with an ECOG PS of 3-4 (P < 0.01). Patients with ≤70 years chose palliative chemotherapy more often than those with > 70 (P < 0.05). And patients with gastric cancer and colon cancer chose palliative chemotherapy more often than those with CUP (carcinoma of unknown primary) (P < 0.05, P < 0.05 respectively). Factors associated with a significantly poorer OS in an adjusted analysis included the ECOG PS and treatment decision (hazard ratios: 0.18 and 0.43; P < 0.001, P < 0.01 respectively). In patients with an ECOG PS of 0-2, palliative chemotherapy was not associated with a longer OS compared with BSC (median OS: 14.5 vs. 6.8 months, respectively; P = 0.144). In patients with an ECOG PS of 3-4, palliative chemotherapy resulted in a significant survival gain compared to with BSC (median OS: 3.8 vs. 1.4 months, respectively; P < 0.05). Strong positive correlations between OS and the length of hospitalization were observed in patients with an ECOG PS of 3-4 who underwent palliative chemotherapy (r² = 0.683) and the length of hospitalization was approximately one-third of their OS.

CONCLUSIONS

The determinants for treatment choice were age, ECOG PS and type of cancer, not sex difference. Oncologists should explain to patients that OS and the length of hospitalization vary according to the ECOG PS when selecting between palliative chemotherapy and BSC.

Chemotherapy use at the End of Life. A Retrospective Single Centre Experience Analysis

Aims and background

The aim of the study was to evaluate the attitude at our institution in using chemotherapy at the end of life in oncology patients. We compared our habits with other clinical patterns in medical oncology, calculating the temporal interval between the last chemotherapy administration and death of the patient.

Patients and methods

We selected and analyzed 102 patients who received chemotherapy for metastatic or advanced solid tumors (breast, colon, gastric, pancreatic and lung cancers) and who died either in or out of a hospital or hospice from June 2007 to the end of 2009.

Results

We compared 51 patients enrolled in clinical trials with 51 patients not enrolled in clinical trials. Patients of both groups died with advanced cancer between June 2007 and 2009. The following solid tumor types were represented: 48% colorectal cancer, 22% breast cancer, 30% other solid tumors (pancreatic, lung and gastric cancer). The median age at death was 62 years (range, 39 to 84), the male/female ratio was 52:50, and 69% of the patients were married. Most patients, 54%, received 2–3 lines of chemotherapy, 25% received more than 3 lines, and the remaining 21% one line only of chemotherapy. Of the 102 patients identified, 16 (16%) received chemotherapy in the last month of life, and 6 (6%) of these in the last 2 weeks. We speculated that the presence of palliative care services in the territory of residence of patients could influence the time interval between the last chemotherapy and death. We found that 52 patients (51%) lived in areas where palliative care services were not available, 27 (52%) of them received chemotherapy in the last 3 months, 8 (15%) in the last month, and 5(10%) within the last 2 weeks of life. In contrast, of the 49 patients living in the territory served by palliative care units or a hospice, none received chemotherapy during the last 2 weeks of life and 37% received it during the last 3 months of life (P = 0.003).

Conclusions

Among selected patients who died for advanced cancer in our Operative Unit from 2007 to 2009, 50% received chemotherapy in the last 3 months of life. The availability of palliative care services in the territory of residence of patients can influence the interval between the last chemotherapy administration and death. Free full text available at www.tumorionline.it

Curative, Life-Extending, and Palliative Chemotherapy: New Outcomes Need New Names

Imprecise terminology obscures the reasons why a cancer patient might be willing to endure the potential toxicities and side‐effects of treatment. Renaming of the categories of chemotherapy is proposed here to clarify intended definitions.

Integrating Palliative Care: A Postmodern Perspective

Hospice and palliative care philosophy is becoming increasingly incorporated into medical practice, education, and research. However, this process of integration may be hindered by continued adherence to several perceived conceptual dichotomies: natural and medicalized death, research and clinical care, and acceptance and denial of dying. These dichotomies were perhaps essential for the initial development of palliative care but could undermine the continuing evolution of care for the terminally ill. In this article, the authors deconstruct these dichotomies and advocate for a fully integrated model of palliative care.

Palliative Chemotherapy Affects Aggressiveness of End-of-Life Care

INTRODUCTION

Although palliative chemotherapy during end-of-life care is used for relief of symptoms in patients with metastatic cancer, chemotherapy may lead to more aggressive end-of-life care and less use of hospice service. This is a population-based study of the association between palliative chemotherapy and aggressiveness of end-of-life care.

PATIENTS AND METHODS

Using the National Health Insurance Research Database of Taiwan, we identified 49,920 patients with metastatic cancer who underwent palliative chemotherapy from January 1, 2009, to December 31, 2011. Patients who received chemotherapy 2-6 months before death were included. Aggressiveness of end-of-life care was examined by previously reported indicators. Cardiopulmonary resuscitation and endotracheal tube intubation were included as indicators of aggressive end-of-life care. The association between palliative chemotherapy and hospice care was studied.

RESULTS

Palliative chemotherapy was associated with more aggressive treatment. After adjustment for patient age, sex, Charlson Comorbidity Index score, cancer group, primary physician's specialty, postdiagnosis survival, hospital characteristics, hospital caseload, urbanization, and geographic regions, more than one emergency room visit (p < .001), more than one intensive care unit admission (p < .001), and endotracheal intubation (p = .02) during end-of-life care were significantly more common in patients receiving palliative chemotherapy. Patients who did not receive palliative chemotherapy received more hospice care in the last 6 months of life (p < .001).

CONCLUSION

Although the decision to initiate palliative chemotherapy was made several months before death, this study showed that palliative chemotherapy was associated with more aggressive end-of-life care, including more emergency room visits and intensive care unit admissions, and endotracheal intubation. The patients who received palliative chemotherapy received less hospice service toward the end of life.

IMPLICATIONS FOR PRACTICE

Palliative chemotherapy is used for patients with incurable cancer toward the end of life (EOL). Aggressiveness of EOL care and hospice care are related to the quality of life of these patients. This study of data from the Taiwanese National Health Insurance Research Database found that palliative chemotherapy led to more aggressive EOL care and less hospice care. There is a need to provide patients with terminal cancer access to care information that best meets their needs, especially those patients who receive palliative chemotherapy.

Usefulness of palliative prognostic score in the treatment of patients with non-resectable gastric cancer

The aim of this study was to evaluate the clinical usefulness of the palliative prognostic (PaP) score in patients with non-resectable advanced gastric cancer. The PaP score was calculated prior to each course of chemotherapy in 44 consecutive patients with non-resectable advanced gastric cancer between 2003 and 2010 at the Tottori University Hospital, Yonago, Japan. The prognosis was evaluated according to the PaP score and the different chemotherapeutic agents. The median survival time (MST) was 10 months. The PaP score classified the heterogeneous patient sample into three isoprognostic groups with regard to the possibility of a 1-month survival period, with 28 patients in group A (>70% chance), 12 in group B (30-70% chance) and 4 in group C (<30% chance). The MST of the three groups was 11, 3 and 1 months for group A, B and C, respectively. In group A, chemotherapeutic regimens did not affect patient survival, although the docetaxel regimen prolonged survival of patients in group B. In conclusion, the PaP score may be useful in selecting the best chemotherapeutic regimen in patients with non-resectable gastric cancer.

Treatment decisions and discontinuation of palliative chemotherapy near the end-of-life, in relation to socioeconomic variables

During the last decades, the possibilities to prolong survival with chemotherapy even in metastatic disease have increased. Our aim was to study treatment decisions and treatment discontinuation decisions in the proximity of death.

METHODS

The medical records of 346 patients with disseminated cancer and a recorded death during 2009 were assessed in relation to demographic and clinical variables and documented treatment decisions were recorded.

RESULTS

Palliative chemotherapy was offered in 54% or these cases and generally one or two regimens were administered, before ending treatment. During the last month of life, 32% received treatment and much more often as an oral (instead of intravenous) treatment than in earlier stages (p < 0.001). Younger patients (p = 0.02) and those with young children (p < 0.001) were treated to a higher degree and also closer to death (p = 0.03). Other variables associated with a higher probability of treatment were high education level (p = 0.001), living with a partner (p = 0.001), female gender (p = 0.023) and ethnicity of non-European origin (p = 0.031). In a multivariate analysis, young age and high education remained as independent factors. In 57% of the cases there was no formal documentation of treatment discontinuation or end-of-life discussions with the patient.

CONCLUSION

Socioeconomic status (SES) is of importance for the treatment decisions. About half of the patients with disseminated disease receive palliative chemotherapy and of these, about one third are treated even during the last month of life. In a majority of cases, there is no formal documentation of treatment discontinuation or end-of-life discussions.

A clinical decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy

BACKGROUND

Palliative chemotherapy is often administered to terminally ill cancer patients to relieve symptoms. Yet, unnecessary use of chemotherapy can worsen patients' quality of life due to treatment-related toxicities. Thus, accurate prediction of survival in terminally ill patients can help clinicians decide on the most appropriate palliative care for these patients. However, studies have shown that clinicians often make imprecise predictions of survival in cancer patients. Hence, the purpose of this study was to create a clinical decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy.

MATERIALS AND METHODS

Data were obtained from a retrospective study of 400 randomly selected terminally ill cancer patients in the National Cancer Centre Singapore (NCCS) from 2008 to 2009. After removing patients with missing data, there were 325 patients remaining for model development. Three classification algorithms, naive Bayes (NB), neural network (NN), and support vector machine (SVM) were used to create the models. A final model with the best prediction performance was then selected to develop the tool.

RESULTS

The NN model had the best prediction performance. The accuracy, specificity, sensitivity, and area under the curve (AUC) of this model were 78%, 82%, 74%, and 0.857, respectively. Five patient attributes (albumin level, alanine transaminase level (ATL), absolute neutrophil count, Eastern Cooperative Oncology Group (ECOG) status, and number of metastatic sites) were included in the model.

CONCLUSIONS

A decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy was created. With further validation, this tool coupled with the professional judgment of clinicians can help improve patient care.

Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model

BACKGROUND

Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of antineoplastic therapy (ANT) in these patients remains controversial. In the current study, the authors examined the frequency and predictors associated with ANT use in hospitalized patients who required admission to an acute palliative care unit (APCU).

METHODS

Included in the study were all 2604 patients admitted over a 5-year period to a 12-bed APCU located within a National Cancer Institute comprehensive cancer center, in which patients had access to both palliative care and ANT. Institutional databases were used to retrospectively retrieve data regarding patient demographics, cancer diagnosis, ANT use, length of hospital stay, and survival from time of admission.

RESULTS

The median hospital stay was 11 days, and the median survival was 22 days. During hospitalization, 435 patients (17%) received ANT, including chemotherapy (N = 297; 11%), hormonal agents (N = 54; 2%), and targeted therapy (N = 155; 6%). No significant change in the frequency of ANT use was detected over the 5-year period. Multivariate logistic regression analysis revealed that younger age, specific cancer diagnoses, and longer admissions were independently associated with ANT use.

CONCLUSIONS

The use of ANT during hospitalization that included an APCU stay was limited to a small percentage of patients and did not increase over time. ANT use was associated with younger age, specific cancer diagnoses, and longer admissions. The APCU facilitates simultaneous care for patients receiving ANT.

Offering Chemotherapy and Hospice Jointly: One Solution to Hospice Underuse

Purpose . Patients with advanced lung cancer typically receive chemotherapy at the cost of receiving care that may promote quality of life more effectively. The authors examined whether offering chemotherapy and hospice concurrently, a clinically appropriate but often unavailable option, might resolve this problem. Method. Adult smokers (N = 198) completed an Internet-based survey in which they imagined having advanced lung cancer. Participants rated the effectiveness of 4 treatments (supportive care alone, chemotherapy with supportive care, hospice, and chemotherapy with hospice) at achieving 4 goals of treatment (extending survival, controlling symptoms, avoiding side effects, and promoting quality of life at the end of life). Results. Reflecting utilization patterns of lung cancer patients, few respondents preferred supportive care alone (10%) or hospice (19%), and many preferred chemotherapy (29%). The most common choice was concurrent chemotherapy and hospice (42%). Treatments that involved chemotherapy were seen as the most effective at extending survival, whereas treatments that involved hospice were seen as most effective at promoting quality of life. Effectiveness ratings were weakly related to preferences for hospice, moderately related to preferences for chemotherapy with supportive care, and strongly related to preferences for chemotherapy and hospice together. Conclusions. These findings suggest that interest in hospice may be low because, offered without chemotherapy, hospice is perceived as ineffective at controlling symptoms and avoiding side effects. Chemotherapy and hospice together may be a preferred option for treating advanced lung cancer. Furthermore, preferences for chemotherapy and hospice together best reflect the values people placed on the goals of treatment.

Integration of a palliative and terminal care center into a comprehensive pediatric oncology department

BACKGROUND

The sharp division between curative cancer therapy and palliative care results in the late introduction of palliative care and a high incidence of suffering in children with cancer. We established a Palliative Care Unit (PCU) that is fully integrated with the Pediatric Hematology Oncology Department (PHOD). We wished to explore the impact of such integrative model on patterns of hospitalizations and exposure to palliative care of pediatric oncology patients.

PROCEDURES

Retrospective search of medical records of patients admitted to the PHOD since PCU establishment in 1999, and of children who died from progressive disease between 1990 and 2005 was performed. Differences in clinical and prognostic variables between PCU and non-PCU patients, and differences in location of death before and after PCU establishment were evaluated.

RESULTS

The majority (59%) of patients, who were hospitalized after the PCU establishment, were hospitalized in the PCU, including 49% of the good prognosis patients and 91% of the poor prognosis patients. Poor prognosis patients were hospitalized in the PCU earlier and with higher frequency compared to children with curable disease. After PCU opening there was a significant decline in the percentage of patients who died in the general pediatric ward, hematology-oncology ward, and at home from 40%, 26% and 28% to 4%, 8%, and 16%, respectively.

CONCLUSIONS

Our integrative model results in exposure of the majority of children with cancer to palliative care. For poor prognosis patients, palliative care is introduced early enough to allow gradual transition from symptom control after diagnosis to end of life care.

The palliative prognostic score and survival in patients with advanced solid tumors receiving chemotherapy

PURPOSE

To evaluate the accuracy of the Palliative Prognostic Score (PaP score) in selecting metastatic gastrointestinal or nonsmall-cell lung cancer patients candidate to palliative chemotherapy.

MATERIALS AND METHODS

The PaP score was calculated in 173 patients with advanced, pretreated gastrointestinal or nonsmall-cell lung cancer before starting a further line of chemotherapy with palliative aim. Symptom distress score was calculated using the Edmonton Symptom Assessment System (ESAS) before every course of chemotherapy. Univariate analysis of survival was performed using the logrank test; multivariate analysis was performed using the Cox regression model. Symptom distress scores were compared using multivariate analysis of variance test for repeated measures, and overall symptom distress score was compared using analysis of variance test for repeated measures.

RESULTS

Overall median survival was 26 weeks; in PaP score class A it was 32 weeks, and in class B 8 weeks (p < 0.0001). No patient was classified in class C. The two-class PaP score resulted in an independent prognostic factor (p = 0.022), as well as Karnofsky performance status (p = 0.002) and colorectal cancer (p = 0.017). A trend towards worsening of symptom distress was observed in the entire population and in class A. The high number of missed data did not permit an adequate analysis in class B.

CONCLUSIONS

The PaP score seems to discriminate patients who could benefit by palliative chemotherapy from those who could better benefit by supportive and palliative approach. However, the data are insufficient to validate the use of the PaP score in patients to be treated with palliative chemotherapy, and further trials should be planned to assess its ability to improve the quality of care in oncology and the appropriateness in the choice of palliative chemotherapy.

Death denial: obstacle or instrument for palliative care? An analysis of clinical literature

As a society and as individuals, we have come to recognize ourselves as 'death-denying', a self-characterisation particularly prominent in palliative care discourse and practice. As part of a larger project examining death attitudes in the palliative care setting, a Medline search (1971 to 2001) was performed combining the text words 'deny' and 'denial' with the subject headings 'terminal care', 'palliative care' and 'hospice care'. The 30 articles were analysed using a constant comparison technique and emerging themes regarding the meaning and usage of the words deny and denial were identified. This paper examines the theme of denial as an obstacle to palliative care. In the articles, denial was described as an impediment to open discussion of dying, dying at home, stopping 'futile' treatments, advance care planning and control of symptoms. I suggest that these components of care together constitute what has come to be perceived as a correct 'way to die'. Indeed, the very conceptualisation of denial as an obstacle to these components of care has been integral to building and sustaining the 'way to die' itself. The personal struggle with mortality has become an important instrument in the public problem of managing the dying process.

The aggressiveness of cancer care in the last three months of life: a retrospective single centre analysis

BACKGROUND

There is concern that terminally ill cancer patients are over treated with chemotherapy, even when such treatment is unlikely to palliate symptoms. The study objective was to evaluate the use of chemotherapy in the last three months of life in a cohort of adult patients with advanced solid tumours.

METHODS

All adult patients with solid tumours who died in our hospital in 2003 and received chemotherapy for advanced cancer, were included. Detailed data concerning chemotherapy and toxicity, in the last three months of life, were collected from patients' clinical charts.

RESULTS

A total of 319 patients were included. Median age was 61 years. Median time from diagnosis of metastatic disease to death was 11 months. The proportion of patients who received chemotherapy in the last three months of life was 66% (n = 211), in the last month 37% and in the last two weeks 21%. Among patients who received chemotherapy in the last three months of life, 50% started a new chemotherapy regimen in this period and 14% in the last month. There was an increased probability of receiving chemotherapy in the last three months of life in younger patients and in patients with breast, ovarian and pancreatic carcinomas.

CONCLUSION

There was a large proportion of patients who received chemotherapy in the last three months of life, including initiation of a new regimen within the last 30 days. Thus, further study is needed to evaluate if such aggressive attitude results in better palliation of symptoms at the end of life.