Accurate Understanding of Chemotherapy Does Not Curtail Late-Life Use, But Improves Odds of Entering Hospice Care

Advanced cancer patients who understand that chemotherapy will not cure their disease are no less likely than those with unrealistic expectations to receive chemotherapy in the final month of life. But patients with an accurate understanding of chemotherapy are more likely to enroll in hospice, according to a report published in Cancer.

“Our findings present a complex picture,” write the authors. “On the one hand, chemotherapy utilization in the last month of life was not a function of baseline expectations that chemotherapy might be curative.” Nor was late use of chemotherapy associated with early preferences for life-prolonging care over comfort care, they note.

However, “patients who recognized that chemotherapy was not curative were more likely to enter hospice, as were patients who preferred comfort-directed care.... Thus, it seems reasonable that patients who recognize that chemotherapy will not cure them may similarly wish to receive hospice care, which is considered a marker of high quality end-of-life care and is associated with better quality of life near death.”

Investigators analyzed follow-up data on patients diagnosed with stage IV lung or colorectal cancer between 2003 and 2005 (n = 722) who were enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study, a population- and health-system-based prospective cohort study. Participants were drawn from five U.S. geographic areas and interviewed within four to six months of diagnosis. All reported having a discussion with a physician about chemotherapy.

Functional Trajectories

• 33.2% of patients recognized that chemotherapy was “not at all” likely to cure their cancer.
• 51% rated their experience of physician communication with the highest possible score.
• Care preferences after diagnosis of metastatic cancer were divided between a wish for life-prolonging (44.0%) and symptom-directed (42.9%) care.
• 18% of all patients received chemotherapy in the last 30 days of life, including 21.7% of those who recognized that chemotherapy was not at all likely to cure their disease.
• Median length of survival following diagnosis was 13 months (range, 8.5 to 24.7 months).
• 35% of all patients enrolled in hospice.

Key Findings

• Patients recognizing that chemotherapy offered no cure were more likely than others to enroll in hospice (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.37 to 2.82), as were patients preferring comfort over life-prolonging care (OR, 1.83; 95% CI, 1.26 to 2.66).
• These patients were also slightly more likely to receive chemotherapy in the last month of life, compared with those who had inaccurate expectations (OR, 1.32; 95% CI, 0.84 to 2.09).
• Patients with a preference for symptom-directed care were also slightly more likely to receive late-life chemotherapy than those preferring life-prolonging care (OR, 0.71; 95% CI, 0.44 to 1.14).
• Nonwhite patients were less likely than whites to use late chemotherapy (OR, 0.52; 95% CI, 0.30 to 0.90), but were also less likely to enroll in hospice (OR, 0.60; 955 CI, 0.40 to 0.90).

Late-life use of chemotherapy was relatively infrequent, yet many patients who used it in the last month of life had declared a preference for comfort care and were aware that chemotherapy offered no chance of a cure. This indicates that some uses of chemotherapy at the end of life may have other goals, such as palliation of symptoms, the authors suggest.

“[A]t least for some patients, late chemotherapy use may be an informed decision based on realistic expectations that it will not be curative,” they note. “However, conversations about the incurable nature of the disease are associated with higher rates of hospice utilization, and this suggests that informed decisions about the goals of care can have a broader impact on care, well beyond an initial decision about treatment.”

The authors suggest future research on the complexities of decision making about chemotherapy, as well as on the framing of such conversations by physicians.

Source: “Patient Beliefs That Chemotherapy May Be Curative and Care Received at the End of Life among Patients with Metastatic Lung and Colorectal Cancer,” Cancer; Epub ahead of print, February 11, 2015; DOI: 10.1002/ cncr.29250. Mack JW, et al. Division of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston.