Jul 24, 2015 -
More cancer patients than ever do advance care planning. That seems like good news, right? Two weeks ago, in JAMA Oncology, Narang and colleagues reported that over 80 percent of cancer patients in the landmark Health and Retirement Study (HRS) had written advance directives, selected a durable power of attorney, discussed end-of-life preferences with loved ones, or otherwise planned for their deaths from their disease.
That same study team, however, found something troubling. Despite all the planning, more of those patients died while undergoing aggressive treatment such as chemotherapy. In fact, they found an eight-fold increase from 2000-2012 in people receiving aggressive end-of-life treatments.
Yesterday, another JAMA Oncology study unveiled a different aspect of the complex story about cancer care towards the end of life. This new study also involved proxy interview data from caregivers of decedents. It showed that patients with life expectancy of six months or less, even those patients with well-preserved functional status, may not benefit from chemotherapy. In fact, it may make their last days worse.
Led by Holly Prigerson, director of the Center for Research on End-of-Life Care at Weill Cornell Medical College, the team studied 312 adults who had six months or less to live due to late-stage lung, colon, breast, or other cancers. About half underwent chemo. After their deaths, 56 percent of caregivers of those who underwent chemo reported that their loved ones had lower quality of life in their last week of life, compared with 31 percent of those who didn't get chemo. There was no difference in survival between the two groups.
"These data from Prigerson and associates suggest that equating treatment with hope is inappropriate," said an accompanying editorial written by SWOG Chair Dr. Charles Blanke and his OHSU Knight Cancer Institute colleague Dr. Eric Fromme, with advice from SWOG Vice-Chair for Translational Medicine Dr. Lee Ellis.
"Let us help patients with metastatic cancer make good decisions at this sad, but often inevitable, stage," they wrote. "Let us not contribute to the suffering that cancer, and often associated therapy, brings, particularly at the end."
In an editorial related to the Narang study about advance directives, I wrote that the way forward begins with better communication by proactive, prepared clinician teams. We need to foster prognostic awareness, focus on the goals of care, and respond to emotions skillfully. This is no small feat. Bousquet and colleagues describe the delivery of bad news as a "balancing act that requires oncologists to adapt continually to different factors." This is one of many challenging aspects of end-of-life cancer care that deserves more attention and research.
As researchers, we not only have to match drugs with genes, we need to work together to discover new and better ways of matching therapy with the goals, values, and preferences of patients and their families.
In SWOG, multiple committees are at the front lines of scientific issues that resonate with patient- and family-centered care: symptom control and quality of life, survivorship, cancer care delivery research, patient advocacy, adolescent and young adult research, and others. Working across committees, and with other NCI network groups, we can advance discovery in the realms of communication, medical decision-making, implementation science, symptom science, and end-of-life care.
This interface of palliative care with oncology is the focus of the ASCO Palliative Care in Oncology meeting now held each fall. The JAMA Oncology articles this month remind us that, in addition to breathtaking advances in cancer treatment, there are other ways that we, as SWOG investigators, can help patients and families.