Learning you have a cancer that looks imminently terminal is tough news to swallow.
And new research indicates that when given just one month to live, a significant number of patients still opt for aggressive and often costly interventions, despite little evidence to suggest they'll help.
A unique population
A study of just over 100 000 patients in the United States found that the urge to undergo ultimately fruitless cancer treatment "is not a rare phenomenon", said study author Dr Helmneh Sineshaw, of the American Cancer Society.
More than one-quarter underwent active treatment, such as surgery or chemotherapy, in the final weeks of life, said Sineshaw, director of treatment patterns and outcomes research for the cancer society.
"Patients newly diagnosed with metastatic cancer who die soon after diagnosis are a unique population," he said. The findings suggest a need to better identify people who would fare better with palliative care – aimed at symptom and stress relief – rather than aggressive and expensive treatments.
Dr Richard Schilsky, chief medical officer for the American Society of Clinical Oncology, agreed that this group is "pretty rare", accounting for just 5% of cancer cases.
"This is a challenging scenario for doctors and patients," Schilsky added. "But oncologists have an obligation to inform their patients as best as they can about the prognosis, the goals of treatment, and the expectations for benefit and side effects from any treatment plan."
Decisions vary widely
For those affected, care planning can be very "complex", said Sineshaw. Decisions involve a tricky interplay of doctors, patients and loved ones, he explained.
"Although there are some guidelines to streamline the decision-making process, a more concerted effort is needed to improve quality of care for these patients," he said.
For the study, Sineshaw's team reviewed data from the US National Cancer Data Base on adult patients newly diagnosed with advanced (metastatic) lung, breast, pancreatic and/or colon cancer between 2004 and 2014.
The analysis confirmed that most – about 73% – do not undergo active treatment during their last month of life.
But many do, although decisions vary widely, depending on the type of cancer involved.
For example, less than 1% of advanced pancreatic cancer patients underwent surgery versus more than 28% of colon cancer patients.
How to avoid unnecessary therapies
And while less than 6% of the terminal colon cancer patients opted for chemotherapy, 11% of lung and breast cancer patients did so.
Similarly, just over 1% of the pancreatic cancer patients chose radiation in their final weeks compared to nearly 19% of lung cancer patients (who accounted for about two-thirds of the study patients).
Aggressive treatment was more common among younger patients, those with no other chronic illness apart from cancer, and those with private insurance, said Sineshaw.
Investigators observed that where someone is treated also matters. For example, lung cancer patients who received care at National Cancer Institute-designated centres were 48% more likely to undergo radiation their last month of life compared with patients treated at a community cancer centre.
Ultimately, the research team concluded that more research is needed to determine why so many patients receive ineffective treatment and to learn how to "avoid unnecessary aggressive and expensive therapies" going forward.
No evidence to suggest a benefit
Schilsky emphasised that "sometimes cancer directed-treatment, particularly radiation therapy, is a necessary and important part of palliative care as it can effectively relieve pain, obstruction or minimise severe bleeding."
But he acknowledged that some patients may not be able to take in expert guidance recommending against treatment when there is no evidence to suggest a benefit.
"It is understandable that some patients will have trouble accepting such recommendations and counselling by hospice, clergy or mental health professionals," Schilsky said.
The findings were published online in the journal JNCI Cancer Spectrum.
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