Chemotherapy Use, Performance Status, and Quality of Life at the End of Life

Abstract

IMPORTANCE Although many patients with end-stage cancer are offered chemotherapy to improve quality of life (QOL), the association between chemotherapy and QOL amid progressive metastatic disease has not been well-studied. American Society for Clinical Oncology guidelines recommend palliative chemotherapy only for solid tumor patients with good performance status. OBJECTIVE To evaluate the association between chemotherapy use and QOL near death (QOD) as a function of patients’ performance status. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional, longitudinal cohort study of patients with end-stage cancer recruited between September 2002 and February 2008. Chemotherapy use (n = 158 [50.6%]) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed at baseline (median = 3.8 months before death) and patients with progressive metastatic cancer (N = 312) following at least 1 chemotherapy regimen were followed prospectively until death at 6 outpatient oncology clinics in the United States. MAIN OUTCOMES AND MEASURES Patient QOD was determined using validated caregiver ratings of patients’ physical and mental distress in their final week. RESULTS Chemotherapy use was not associated with patient survival controlling for clinical setting and patients’ performance status. Among patients with good (ECOG score = 1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOD (odds ratio [OR], 0.35; 95% CI, 0.17-0.75; P = .01). Baseline chemotherapy use was not associated with QOD among patients with moderate (ECOG score = 2) baseline performance status (OR, 1.06; 95% CI, 0.51-2.21; P = .87) or poor (ECOG score = 3) baseline performance status (OR, 1.34; 95% CI, 0.46-3.89; P = .59). CONCLUSIONS AND RELEVANCE Although palliative chemotherapy is used to improve QOL for patients with end-stage cancer, its use did not improve QOD for patients with moderate or poor performance status and worsened QOD for patients with good performance status. The QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death, even in patients with good performance status.

A randomized phase II feasibility trial of a multimodal intervention for the management of cachexia in lung and pancreatic cancer

“…From a patient perspective, weight loss is associated with psychosocial distress30, 31 whilst deteriorating physical function (e.g. performance status) is associated with reduced quality of life 32, 33. Based on our observations and supported by previous work, we propose that weight loss and physical function are favourable endpoints in cancer cachexia trials, being meaningful for both patients and oncologists.…”

Comparative Survival in Patients with Brain Metastases from Non-small-Cell Lung Cancer Treated before and after Implementation of Radiosurgery

“…The goals of treatment are to minimize toxicity and to maximize both length and quality of life 10,11 . Previous evaluation of a cohort of nsclc patients with bMets at our institution treated primarily with whole-brain radiation therapy (wbrt) with or without surgery demonstrated a median survival of approximately 4 months from diagnosis with bMets 12 .…”

“…The improved toxicity profile associated with newer radiation techniques such as stereotactic radiosurgery (srs)-in particular, the reduction in late toxicities-has led to a paradigm shift in treatment 4 . The sophisticated planning and imaging techniques in srs target cranial lesions with high levels of precision 8 , permitting an escalation of the radiation dose to the target lesion or lesions, while sparing the surrounding normal tissues [5][6][7][8][9][10][11] . Traditional wbrt has been supplemented with, and more recently replaced by, srs alone [5][6][7][8][9] .…”

“…There is a rationale to consider srs because of its better side-effect profile compared with that for wbrt 7,10 and its ability to successfully salvage additional bMets [5][6][7]9 . The sustained control of new central nervous system metastases with the use of salvage srs might permit more aggressive management of extracranial disease and could potentially increase overall survival (os) for these patients 11 .…”

Palliative Chemotherapy Affects Aggressiveness of End-of-Life Care

“…High-quality end-of-life (EOL) care includes decision making, survival, symptom management, psychosocial support, and hospice care [5]. Although palliative chemotherapy near the EOL is used for relief of symptoms [6,7], palliative chemotherapy may lead to poorer quality of life near death compared with palliative treatment [8].…”