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BMJ. May 26, 2001; 322(7297): 1267.
PMCID: PMC1120378

Chemotherapy may be overused at the end of life

Many patients with cancer receive chemotherapy at the end of life, even if their kind of cancer is known to be unresponsive to the drugs, according to a study reported at the recent annual meeting of the American Society of Clinical Oncologists held in San Francisco.

The finding “strongly suggests overuse of chemotherapy at the end of life,” lead author Dr Ezekiel Emanuel, chairman of the department of clinical bioethics at the US National Institutes of Health, told delegates. “Many are concerned with the quality of end of life care and specifically that patients should not be overtreated with ineffective therapies that won't improve their quality of life,” he said.

Dr Emanuel and his team looked at the billing records of nearly 8000 patients who died of cancer in the state of Massachusetts in 1996. They found that 41% of patients received chemotherapy in the final year of life, 33% in the final six months, and 25% in the final three months.

The researchers then divided the patients into two groups to see if the chemotherapy treatment was appropriate or inappropriate. One group of patients had cancer types that are responsive to chemotherapy (namely, the treatment shrinks the tumour) and the other had cancers considered to be non-responsive.

Dr Emanuel's team used standard textbooks to classify whether different cancers were generally responsive or unresponsive to chemotherapy. Responsive cancers included in the study were breast, colon, and ovarian. Unresponsive cancers included gallbladder, kidney, liver, pancreatic, and melanoma.

The researchers found that at six months, three months, and one month before death, the use of chemotherapy between the two groups of patients did not differ. Chemotherapy was given with the same frequency.

Additional studies are needed before such findings can be confirmed nationally and guidelines can be developed on when chemotherapy should be stopped in terminal cases, Dr Emanuel said. In addition, he said, studies are needed to understand better how the interaction among doctors, patients, and families influences the use of chemotherapy in terminal stages of cancer.

Dr Emanuel also noted that treating patients with chemotherapy in the final year of life is expensive—$38308 (£27360), compared with $27567 for patients not in the final year of life. “We are going to need to do a lot of research to figure out what is driving the need for chemotherapy during the last months of life, especially for patients with unresponsive cancers,” he said.

David Kerr, professor of clinical oncology at Birmingham University, commenting on the US study, said he thought that there would be less use of chemotherapy in the final year of life in the United Kingdom, for several reasons. “We tend to adhere to evidence based treatment guidelines,” he said. “We are also under sufficient ‘pressure’ treating the curable and moderately chemosensitive tumours without wasting resource on unproven treatments.”


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