Who wants second-line, palliative chemotherapy?

Endocrine treatment near the end of life among older women with metastatic breast cancer: a nationwide cohort study

Background

The appropriate time to discontinue chemotherapy at the end of life has been widely discussed. In contrast, few studies have investigated the patterns of endocrine treatment near death. In this study, we aimed to investigate the end-of-life endocrine treatment patterns of older women with metastatic breast cancer and explore characteristics associated with treatment.

Methods

A retrospective cohort study of all older women (age ≥65 years) with hormone receptor-positive breast cancer who died in Sweden, 2016 - 2020. We used routinely collected administrative and health data with national coverage. Treatment initiation was defined as dispensing during the last three months of life with a nine-month washout period, while continuation and discontinuation were assessed by previous use during the same period. We used log-binomial models to explore factors associated with the continuation and initiation of endocrine treatments.

Results

We included 3098 deceased older women with hormone receptor-positive breast cancer (median age 78). Overall, endocrine treatment was continued by 39% and initiated by 5% and of women during their last three months of life, while 31% discontinued and 24% did not use endocrine treatment during their last year of life. Endocrine treatment continuation was more likely among older and less educated women, and among women who had multi-dose drug dispensing, chemotherapy, and CDK4/6 use. Only treatment-related factors were associated with treatment initiation.

Conclusion

More than a third of women with metastatic breast cancer continue endocrine treatments potentially past the point of benefit, whereas late initiation is less frequent. Further research is warranted to determine whether our results reflect overtreatment at the end of life once patients' preferences and survival prognosis are considered.

Relevant Study: Patient and Clinician Perspectives on Clinically-Meaningful Outcomes in Advanced Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with a poor prognosis and significant symptom burden. This prospective observational study aimed to evaluate expectations and priorities of patients with advanced PDAC and their clinicians through a study survey and two quality of life (QoL) questionnaires (QLQ-C30 and PAN26) at three time-points: baseline (T1), before (T2) and after (T3) their 1st on-treatment CT scan. Over a 1-year period, 106 patients were approached, 71 patients and 12 clinicians were recruited. Choosing between treatment options, patients prioritised: 54% overall survival (OS), 26% balance between side-effects and OS, 15% could not choose and 5% favoured symptom control. These were significantly different from the clinician's answers (p < 0.001). Patients who prioritised OS had higher symptom burden (p = 0.03) and shorter OS compared to those who prioritised balance (p = 0.01). Most (86%) patients had personal goals they wanted to reach; clinicians knew of these in 12% of instances. Patient and clinicians' views regarding survival improvement from chemotherapy were significantly different: 81% of clinicians and 12% of patients thought 1-2 or 3-6 months extension, 58% of patients and 0% physicians thought 1-5 or >5 years (p < 0.001). At T1, patients had low QoL and worst symptoms were: 'Future worries', 'planning of activities', fatigue and pain. Patients were willing to accept significantly higher amounts of side-effects as a trade-off for extra time, than clinicians thought (p < 0.001). Overall, there are significant discrepancies between patient and clinicians' views about the aims, priorities and expected extension of life.

Factors affecting medication beliefs among patients newly prescribed oral oncolytic agents

BACKGROUND

Prescribing oral oncolytic agents (OAs) for advanced cancers is increasing.

AIMS

To explore changes in medication beliefs and the effects of symptom severity, cognitive effectiveness and depressive symptoms on medication beliefs over 12 weeks.

METHODS

Secondary analysis of a randomized controlled trial, testing an intervention to promote symptom management and adherence [N = 230]. Questionnaires evaluated medication beliefs, symptom severity, depressive symptoms, and cognitive effectiveness. Linear mixed effects models were used for analyses.

RESULTS

OA Necessity beliefs increased over time (mean difference 0.0112, SE = 0.055, p 0.04). Concern beliefs did not change and were lower for advanced cancers (-0.193, SE = 0.067, p < 0.01).Depressive symptoms were related to decreased Necessity beliefs (-0.012, SE = 0.005, p = 0.02), but not Concern beliefs. Medication beliefs were not associated with symptom severity or cognitive effectiveness.

CONCLUSION

Patients with advanced cancer hold different medication beliefs compared to earlier staged cancers, lending insight into potential outcomes beyond adherence.

How adverse events and permanent medication stoppages affect changes in patients' beliefs about oral antineoplastic agents

BACKGROUND

Patients with advanced cancer often experience adverse events related to oral antineoplastic agents (OAAs) and permanent OAA medication stoppages, yet it is unknown how these factors impact medication beliefs. Such beliefs about OAA therapy may lend insight into decisions about continued cancer treatment near the end of life.

PURPOSE

To explore relationships that adverse events and permanent OAA stoppages have on medication beliefs during the first 12 weeks following new OAA initiation.

DESIGN

A secondary data analysis from a National Cancer Institute-funded randomized controlled trial testing an intervention to promote symptom management and OAA adherence.

SETTING/SUBJECTS

Patients ≥ 21 years of age initiating a new course of OAA medication were recruited from six United States Comprehensive Cancer Centers. This analysis was based on a subset of patients with advanced disease (N = 60).

MEASUREMENTS

Beliefs about Medicine Questionnaire, Common Terminology Criteria for Adverse Events, and medical records of permanent OAA stoppages.

RESULTS

Significant decline in beliefs regarding the necessity of OAA medications existed between patients experiencing three or more adverse events and those experiencing a permanent OAA stoppage.

CONCLUSIONS

Beliefs about the necessity of OAA medication change when physicians stop OAA medication or the patient experiences three or more adverse events. Concern regarding OAA medication did not change in response to medication stoppage or adverse events for this sample. Perhaps, patients with advanced cancers may be more accepting of adverse events that occur along the treatment trajectory and are not concerned about OAA medication once it is stopped. Findings suggest the importance of physicians' discussions of adverse events and decisions to permanently stop OAA medication as a means of transitioning to a new phase of cancer care that may include palliative or hospice considerations, given that beliefs about medication necessity are changing during these threats to cancer treatment.

Quality of palliative care in identified palliative care beds

BACKGROUND

Dedicated identified palliative care beds (IPCB) are unique to France.

AIMS

This study aimed to assess their use and advantages in a medical oncology department of a private provincial hospital.

FINDINGS

Of the last 100 patients who died in the medical oncology department, 57 had an IPCB. Those with an IPCB had a longer final hospital stay and significant advantages for them were access to pain evaluation by nurses and professional psychological support. Opioid use was higher, but not significantly so. There were no significant differences for the presence of close relatives, physiotherapy interventions, social workers or specific anti-cancer treatment in the last 15 days of life.

CONCLUSION

This study shows some advantages for IPCB (treatment of pain, psychologist), which should be further explored. The length of the final hospital stay is controversial.

Over-treatment in metastatic breast cancer

Metastatic breast cancer is an incurable disease and the main goals of treatment are prolongation of survival and preservation/improvement of quality of life. Thus the main philosophy of treatment should be to use the least toxic methods, as long as they provide sufficient disease control. In ER-positive tumours this can be in many cases achieved by endocrine therapy; in HER2-positive cancers efficacy of backbone therapy can be enhanced by an anti-HER2 agent. In patients requiring chemotherapy, consecutive single agent regimen provide disease control of a duration at least comparable to multidrug regimen, at a cost of significantly lower toxicity and are a preferred strategy in the majority of cases. Available data demonstrate, however, that aggressive chemotherapy is still overused in many metastatic breast cancer patients. The objective of this manuscript is to critically review available data on treatment choices and sequence in metastatic breast cancer across all breast cancer subtypes in relation to possible overtreatment, including therapies which are not recommended by current guidelines or not even approved. Our aim is to provide guidance on applying these data to clinical practice, but also to describe various, often non-scientific factors influencing therapeutic decisions in an aim to identify areas requiring educational and possibly political actions.

Routine assessment of performance status during palliative chemotherapy when approaching end-of-life

PURPOSE

Palliative chemotherapy treatment (PCT) offered late in the cancer disease trajectory may be problematic. It is not easy to accurately calculate whether the potential benefits will outweigh the side-effects. This study investigates whether routine use of the Performance Status in Palliative Chemotherapy questionnaire (PSPC) affects the proportions of patients receiving PCT during the last month of life, care utilization, and documentation routines. A secondary aim was to gather registered nurses' experiences of the PSPC in routine use.

METHODS

Eighty incurable patients with cancer who had used the PSPC before PCT were compared to 160 matched controls, using non-parametric tests. Nurses' reflections on the PSPC were collected and reviewed.

RESULTS

No significant differences were found between users and non-users of the PSPC in terms of proportions receiving PCT during the last month of life. Higher proportions of patients older than 74 years received PCT than in previous studies (40% versus 17%). Nurses considered the questionnaires to be a valuable complement to verbal information when trying to acquire an accurate picture of patients' performance status.

CONCLUSION

At this point in the development of the PSPC we did not find any significant decreases in the proportion of patients receiving PCT during the last month in life. However, as the nurses valued the PSPC, it can be used as a complementary tool in assessment of performance status until further research is conducted.

Living better or living longer? Perceptions of patients and health care professionals in oncology

BACKGROUND

Cancer can influence the views of patients on treatment goals and make them different from those of health care professionals (HCPs). It is crucial to understand patient expectations regarding cancer treatment.

METHODS

We performed a cross-sectional survey of patients with cancer and HCPs to evaluate their perceptions about treatment priorities and to analyse variables that might influence their opinions. To identify treatment choices, we interviewed all participants using a structured questionnaire with fictitious case vignettes.

RESULTS

We enrolled a total of 230 participants, including 144 patients and 86 HCPs (35 nurses, 21 physicians, 30 others). Treatment priority between survival time (28.5% for patients vs. 8.1% for HCP) and quality of life (45.8% vs. 87.2%) differed significantly, with the remaining participants stating they were uncertain or unwilling to respond, or providing invalid responses (P < 0.01). In logistic regression, prioritising survival time was more frequent in patients, adjusting for age and gender (odds ratio (OR) = 3.95; P < 0.01). The view that the physician alone should be responsible for treatment choices was more frequent among patients than HCPs (18.8 vs. 5.8%; P = 0.01).

CONCLUSIONS

In Brazil, our results suggest that survival time is more important for patients with cancer than for HCPs, whereas quality of life is more important for HCPs than for patients with cancer, who place great emphasis on physicians as decision-makers. Given that Brazilian patients often rely on physicians for decisions, the potential impact of different priorities between survival time and quality of life when patients and HCPs are compared is unknown.

Differences in attitude toward adjuvant chemotherapy between colorectal cancer survivors and the medical staff of Japanese hospitals

BACKGROUND

Adding oxaliplatin to fluorouracil-based chemotherapy can improve the survival of patients with stage III colorectal cancer by approximately 20 %. Reportedly, cancer patients are much more likely to prefer chemotherapy than medical professionals, although there is only a very small chance of achieving benefits from treatment. However, chronic neurotoxicity may be long lasting after the administration of oxaliplatin-based chemotherapy. This study aimed to evaluate potential side effects and differences in attitude between colorectal cancer patients and medical staff regarding the risk-benefit trade-offs of chemotherapy.

METHODS

Relapse-free colorectal cancer patients who received adjuvant chemotherapy, doctors, and nurses were surveyed using a questionnaire regarding the side effects of chemotherapy and hypothetical clinical scenarios to quantify gains in the risk of relapse that were deemed necessary to make chemotherapy worthwhile.

RESULTS

Responses were obtained from 147 patients, 54 doctors, and 84 nurses. Of these, 39 % of patients and 85 % of doctors replied that moderate side effects of adjuvant chemotherapy were worthwhile to achieve an absolute gain in the risk of relapse of 10 % from a baseline of 40 %. More severe side effects, as reported by colorectal cancer patients, were not associated with the larger gains necessary to make treatment worthwhile. Seven percent of patients treated with oxaliplatin, 40 % of doctors, and 43 % of nurses replied that side effects associated with oxaliplatin-based chemotherapy were severe.

CONCLUSIONS

Doctors should consider potential heterogeneity in side effects and attitudes regarding the risk-benefit balance of adjuvant chemotherapy, and that patient perspectives should enhance shared decision-making.

Treatment priorities in oncology: do we want to live longer or better?

OBJECTIVES

Despite the progress achieved in the fight against cancer over the past several years, assessing the needs, goals and preferences of patients with cancer is of the utmost importance for the delivery of health care. We sought to assess priorities regarding quantity versus quality of life among Brazilian patients, comparing them with individuals without cancer.

METHODS

Using a questionnaire presenting four hypothetical cancer cases, we interviewed cancer patients, oncology health-care professionals and laypersons, most of whom had administrative functions in our hospital.

RESULTS

A total of 214 individuals participated: 101 patients, 44 health-care professionals and 69 laypersons. The mean ages in the three groups were 56, 34 and 31 years old, respectively (p<0.001). The patients had gastrointestinal (25%), breast (22%), hematologic (10%), lung (8%) or other tumors (36%) and the tumor-node- metastasis (TNM) stage was I, II, III or IV in 22%, 13%, 34% and 31% of cases, respectively. Treatment priorities differed significantly among the three groups (p = 0.005), with survival time being a higher priority for patients than for the other two groups and with opposite trends regarding quality of life. In multivariate analysis, the age and sex distributions were not associated with the choice to maximize quality of life. In this limited sample of cancer patients, there were no associations between treatment priorities and disease stages.

CONCLUSIONS

Both survival time and quality of life appeared to be important to cancer patients, oncology health-care professionals and laypersons, but survival time seemed to have higher priority for people diagnosed with cancer than for healthy people. Additionally, survival seemed to be more important than quality of life for all three groups assessed.

Predictors of symptoms and site of death in pediatric palliative patients with cancer at end of life

OBJECTIVE

To describe how preferences and treatment influence symptoms at end of life and site of death in pediatric cancer.

METHODS

We included 61 pediatric palliative patients with cancer whose parents previously participated in a study that elicited preferences for aggressive chemotherapy versus supportive care alone and who subsequently died. Main outcomes were severe pain and dyspnea proximal to death and site of death.

RESULTS

Choice of aggressive chemotherapy predicted significantly more severe pain (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.0-9.6; P = .049). Intravenous chemotherapy 4 weeks before death predicted severe dyspnea (OR 15.8, 95% CI 3.7-67.5; P < .001) and death outside the home (OR 0.3, 95% CI 0.1-0.9; P = .038).

CONCLUSIONS

Parental choice of aggressive chemotherapy and more aggressive treatment proximal to death predicted more pain, dyspnea, and death in hospital. Strategies to improve quality of life are needed.

[The importance of individual beliefs about cancer treatments for therapeutic decisions]

Interest for representations about cancer treatments and their side effects is increasing because their central role has been proved in how patients cope with illness and symptoms and how they react emotionally. Through a synthesis of the literature, this paper has two objectives: firstly, to clarify the current state of knowledge in this field, and secondly to point out the manner that bringing out these individual representations during oncological consultations contributes to preventing difficulties and treatment discontinuation and facilitates medical decision processing.

Patients' perspectives on palliative chemotherapy of colorectal and non--colorectal cancer: a prospective study in a chemotherapy- experienced population

BACKGROUND

A better understanding of patients' views on the benefit and burden obtained from palliative chemotherapy would facilitate shared decision making. We evaluated palliative cancer patients' reported outcomes (PROs) for toxicity and investigated the survival threshold for which they would repeat chemotherapy (CTx).

METHODS

Patients who had received a minimum of three months of palliative CTx for advanced colorectal (CRC) or non-colorectal (non-CRC: upper gastrointestinal, lung and head-and-neck) cancer were assessed by questionnaire. Patients were questioned about PROs for toxicity, subjective burden from side effects, and were asked for the survival threshold necessary for them to repeat CTx. Expected survival (sum of indicated survival threshold and median survival time with best supportive care) was compared to the patients' actual survival.

RESULTS

One hundred and thirty-four patients (CRC: 58; non-CRC: 76) were surveyed. The most frequent PRO- grade 3/4 toxicities were acne (12.8%), fatigue (9.0%), and diarrhea (8.5%). The symptom causing the highest subjective burden was fatigue and was worse than expected in 29.9% of the patients. The median survival threshold for which patients would repeat CTx was significantly longer in CRC than in non-CRC patients (p=0.01). Median expected survival was significantly longer than actual median survival (CRC: 44.0 months [22.0-65.9] compared with 30.0 months of actual survival [20.9-39.1]; non-CRC: 22.0 months [15.3-28.6] compared with 19.0 months of actual survival [15.1-22.9], p=0.03).

CONCLUSION

Fatigue deserves more attention when toxicity of treatment and symptoms of disease are explained to patients. Patients' survival expectations from palliative chemotherapy are higher than previously described, exceed the median survival time known from phase III trials, and are significantly longer than their actual survival.

Out-of-pocket expenses and treatment choice for men with prostate cancer

OBJECTIVE

To describe the knowledge of, and attitudes toward, out-of-pocket expenses (OOPE) associated with prostate cancer treatment and the influence of OOPE on the treatment choices of patients with prostate cancer.

MATERIALS AND METHODS

We undertook a qualitative research study for which we recruited patients with clinically localized prostate cancer. Patients answered a series of open-ended questions during a semistructured interview and completed a questionnaire about the physician's role in discussing OOPE, the burden of OOPE, the effect of OOPE on treatment decisions, and previous knowledge of OOPE.

RESULTS

A total of 41 (26 white and 15 black) eligible patients were enrolled from the urology and radiation oncology practices of the University of Pennsylvania. Qualitative assessment revealed 5 major themes: (a) "my insurance takes care of it"; (b) "health is more important than cost"; (c) "I did not look into it"; (d) "I cannot afford it but would have chosen the same treatment"; and (e) "It is not my doctor's business." Most patients (38 of 41, 93%) reported that they would not have chosen a different treatment even if they had known the actual OOPE of their treatment. Patients who reported feeling burdened by OOPE were socioeconomically heterogeneous, and their treatment choices remained unaffected. Only 2 patients stated they knew "a lot" about the likely OOPE for different prostate cancer treatments before choosing their treatment.

CONCLUSION

Among insured patients with prostate cancer treated at a large academic medical center, few had knowledge of OOPE before making treatment choices.

Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study

OBJECTIVE

To compare the survival and risk of serious adverse events in older patients with stages II-IIIA non-small cell lung cancer treated with or without postoperative platinum based chemotherapy.

DESIGN

Observational cohort study.

SETTING

Cases of lung cancer in Surveillance Epidemiology and End Results registry linked to Medicare files, 1992-2005, and follow-up data to December 2007.

PARTICIPANTS

3324 patients aged more than 65 years with resected stages II-IIIA lung cancer.

MAIN OUTCOME MEASURES

Primary outcome was overall survival and secondary outcome was the rate of serious adverse events among older patients treated with or without adjuvant chemotherapy.

RESULTS

Overall, 21% (n = 684) of patients received platinum based chemotherapy. Analyses adjusted, stratified, or matched by propensity scores showed that chemotherapy was associated with improved survival (hazard ratio range 0.78-0.81). The beneficial effect of chemotherapy was also observed among patients treated with radiation therapy (0.75-0.77) or without radiation therapy (0.74-0.77); however, chemotherapy was not beneficial for patients aged 80 or more (1.32-1.46). Adjuvant chemotherapy was associated with an increased odds of serious adverse events (odds ratio 2.0, 95% confidence interval 1.5 to 2.6).

CONCLUSIONS

Platinum based adjuvant chemotherapy is associated with reduced mortality and increased risk of serious adverse events in older patients with stages II-IIIA lung cancer. The magnitude of the benefit is similar to that observed in randomised controlled trials carried out among selected patients.

A model of treatment decision making when patients have advanced cancer: how do cancer treatment doctors and nurses contribute to the process?

This qualitative study describes how doctors and nurses report their contribution to treatment decision-making processes when patients have advanced cancer. Thirteen nurses and eight doctors involved in cancer treatment and palliation in one geographical location in New Zealand participated in the study. Data were collected using qualitative in-depth, face-to-face interviews. Content analysis revealed a complex context of decision making influenced by doctors and nurses as well as the patient and other factors. A model of clinician and patient decision making emerged with a distinct and cyclical process as advanced cancer remits and progresses. When patients have advanced cancer, nurses and doctors describe a predictable model of decision making in which they both contribute and that cycles through short- and long-term remissions; often nowadays to the point of the patient dying. In conclusion, the findings suggest doctors and nurses have different but complementary roles in what, when and how treatment choices are negotiated with patients, nevertheless within a distinct model of decision making.

Reliability and validity of the EORTC QLQ-C30 in palliative care cancer patients

Palliative care aims at improving the patient’s quality of life. The assessment of this quality of life (QoL) is crucial for the evaluation of palliative care outcome. Many patients require hospital admissions for symptom control during their cancer journey and most of them die in hospitals, although they would like to stay at home until the end of their lives. In 1986, the European Organization for Research and Treatment (EORTC) initiated a research programme to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. This questionnaire measures cancer patients’ physical, psychological and social functions and was used in a wide range of clinical cancer trials with large numbers of research groups and also in various other non-trial studies. The aim of this study was to evaluate the psychometric properties, especially the reliability, validity and applicability of the EORTC QLQ-C30 in a German sample of terminally ill cancer patients receiving palliative care in different settings. The questionnaire was well accepted in the present patient population. Scale reliability was good (pre-treatment 0.80) especially for the functional scale. The results support the reliability and validity of the QLQ-C30 (version 3.0) as a measure of the health-related quality of life in German cancer patients receiving palliative care treatment.

Factors that affect the duration of the interval between the completion of palliative chemotherapy and death

BACKGROUND

The purpose of this study was to identify factors that affect the duration of the interval between the completion of palliative chemotherapy and death.

METHODS

We retrospectively analyzed 255 cases in which patients had received palliative chemotherapy in the medical oncology division and died during the period 2002-2006. Univariate and multivariate analyses were performed to identify factors that affected the duration of the interval between the completion of chemotherapy and death.

RESULTS

There were 133 cases of breast cancer, 77 cases of gynecological cancer, 24 cases of primary unknown cancer, and 21 cases of other cancers. The median interval between the completion of chemotherapy and death was 100 days (range, 5-1,206 days). Thirty-two patients (12.6%) died within 30 days, and 82 patients (32.3%) died within 60 days. Fifty-eight (22.7%) patients were symptomatic when chemotherapy was started, and 205 patients (80.4%) were provided information about palliative care units at the start of chemotherapy. The factors associated with a short interval between the completion of chemotherapy and death (< or = 90 days) according to the univariate analysis were male sex, young age (< or = 45 years), attending physician, poor Eastern Cooperative Oncology Group performance status score (3 or 4), obvious symptoms, and not having been given information about palliative care units. The results of the multivariate analysis indicated that young patients (< or = 45 years) who had not been referred to a palliative care unit and who had symptoms survived for a significantly shorter time interval.

CONCLUSION

Young patients who were symptomatic tended to choose chemotherapy instead of entering a palliative care unit until the very near-the-end-of-life stage.

End-of-life planning and its relevance for patients' and oncologists' decisions in choosing cancer therapy

The goal of end-of-life (EoL) planning is to provide individuals with tools to control their financial and healthcare decisions when they are incapacitated. When an elderly patient is diagnosed with advanced cancer, the possible treatment options are palliative care with curative intent or prolongation of life or palliative care only. Treatment of cancer in elderly patients creates a significant array of monetary and symptom burdens. The question is whether advance care planning, part of EoL planning, allows patients' families and communities to control and reduce these burdens. Although the number of patients completing advance directives has increased in recent years, there are multiple barriers to the implementation of patients' wishes, such as limited knowledge of patient wishes by proxy and physician and inadequate communication regarding prognosis. In this article, the authors propose that improvements in patient decision making and clinical practice can reduce the burden of symptoms for patients if clinicians gain a better understanding of patients' models and expectations respecting the longer term consequences of diagnosis and treatment. This understanding can arise from improved information exchange and constant updating of the information as the disease and treatment evolves. Clinicians also need better prognostication tools and better training in effective communication skills to elicit patient goals and to make appropriate recommendations.

The role of chemotherapy at the end of life: "when is enough, enough?"

Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed.

Treatment options in end-of-life care: the role of palliative chemotherapy

Advances in medical science and technology, combined with the primary goal of medical care to restore or maintain health as far as possible, often result in the transition from active to palliative care being blurred. Treatment choices are limited in advanced disease; but paradoxically, which therapy to choose is becoming an increasingly complex decision (Weissman, 2004). The role of chemotherapy in this phase remains a controversial subject, but data are emerging to show that an increasing number of patients nearing the end of life are receiving chemotherapy (Matsuyama et al, 2006), and there is a mounting body of evidence for its use in symptom palliation (Cullen, 2003; Bowcock et al, 2004; Davis, 2005). Therefore, the traditional view that medical oncology and palliative care are two distinct disciplines may need to be modified.

Patient attitudes towards chemotherapy as assessed by patient versus physician: a prospective observational study in advanced non-small cell lung cancer

BACKGROUND

In the treatment of advanced cancer, a physician's ability to accurately identify a patient's attitude towards treatment is critical. This paper describes the extent of any differences observed between patient attitudes towards chemotherapy for advanced non-small cell lung cancer (NSCLC) as assessed by patients themselves versus their physicians.

PATIENTS AND METHODS

Patients with stage IIIB or IV NSCLC who received gemcitabine plus cisplatin or carboplatin were enrolled into this prospective observational study. Patients and their physicians completed questionnaires containing descriptions of seven patient-specific attitudes. A pre-defined algorithm was used to categorize patients into one of the three 'need' categories based on the questionnaire responses: (A) "maximum extension of survival with acceptance of high toxicity", (B) "maximum extension of survival only if coupled with normal life style", and (C) "relief of symptoms". Each patient was categorized based on his own response, as well as his physician's response.

RESULTS

A total of 1895 patients were enrolled from 19 countries across 3 continents. Data from 1884 patients were analysed. Based on patient versus physician responses, respectively, the distribution of patients was 60% versus 39% in need category A, 26% versus 33% in B, and 14% versus 29% in C. Patient self-assessed versus physician-assessed need category identification was aligned for 891 patients (47.3%): 541 (29%) in A, 218 (12%) in B, 132 (7%) in C. While there was slight agreement between the identification of 'need' categories by physicians and patients (kappa=0.18, 95% CI: 0.15-0.21), physicians also tended to place patients further down the scale (towards C) than patients placed themselves (P<0.001).

CONCLUSIONS

Patients have varying needs from cancer chemotherapy and it may not always be correctly identified by the treating physician. Physicians may underestimate patient's desire for extended survival compared with symptom relief.

Why Do Patients Choose Chemotherapy Near the End of Life? A Review of the Perspective of Those Facing Death From Cancer

Purpose

The number of patients receiving chemotherapy near the end of life is increasing, as are concerns about goals of treatment, toxicity, and costs. We sought to determine the available sources of knowledge, the choices, and concerns of actual patients, and how patients balanced competing issues.

Methods

We used a literature search from 1980 to present.

Results

Available patient sources provide little information about prognosis, choices, alternatives, consequences, or how to choose. Many patients would choose chemotherapy for a small benefit in health outcomes, and for a smaller benefit than perceived by their health care providers for their own treatment. Adverse effects are less a concern for patients than for their well health care providers. There are no decision aids to assist patients with metastatic disease in making their choices, such as there are for adjuvant breast therapy.

Conclusion

The perspective of the patient is different from that of a well person. Patients are willing to undergo treatments that have small benefits with major toxicity. Receiving realistic information about the different options of care and the likelihood of successful treatment or adverse effects is difficult. These factors may explain some of the increased use of chemotherapy near the end of life. Decision aids and honest, unbiased sources to inform patients of their prognosis, choices, consequences, typical outcomes, and ways to make decisions are needed. More prospective information about how patients make their choices, and what they would consider a good choice, would assist informed decision making.

Hope and probability: patient perspectives of the meaning of numerical information in cancer communication

Although the complexities inherent in human communication make it a difficult target for empirical investigation and systematic interpretation, it is well recognized that patient-provider communication can have either a powerfully negative or positive influence on the experience of cancer. Drawing on an extensive data set derived from interviews with 200 cancer patients, the authors examine the impact of information provided in numerical form within cancer care communications from the patient perspective. In this context, they present findings related to various uses and abuses of numbers within cancer care communication, and illustrate how numerical information constitutes a specialized communication form with considerable potency for shaping the cancer experience. In particular, accounts of the thematic relationship between numbers and hope, from the perspective of those on the receiving end of cancer care, provide a unique perspective from which to interpret issues of compassion, caring, and informed consent.

Advanced Breast Cancer Patients' Perceptions of Decision Making for Palliative Chemotherapy

Purpose

To examine advanced breast cancer patients' perceptions of the key decision-making consultation for palliative chemotherapy.

Patients and Methods

One hundred two women with advanced breast cancer, who were offered palliative chemotherapy, participated in a study-specific semistructured interview examining perceptions of the information they had received and their involvement in the decision-making process. One hundred seventeen interviews included 70 in relation to first-line chemotherapy and 47 in relation to second-line chemotherapy (15 patients were interviewed in relation to both first- and second-line chemotherapy).

Results

Eighty-six percent of patient interviews (n = 101) reported patient satisfaction with the information they received, and 91% (n = 106) reported satisfaction with the decision-making process. Factors most influential in decisions to accept chemotherapy were the possibility of controlling the tumor (45%, n = 53 of patient interviews) and providing hope (33%, n = 28 of patient interviews; 19%, n = 13 being offered first-line chemotherapy v 43%, n = 20 being offered second-line chemotherapy; P = .006). Thirty-eight percent of patient interviews (n = 44) reported the patient as taking an active role in the decision-making process (33%, n = 23 at first-line chemotherapy v 43%, n = 20 at second-line chemotherapy; P = .06).

Conclusion

Women offered second-line chemotherapy were more likely to undergo chemotherapy because of the hope it offers and were more likely to take an active role in that decision compared with women who were offered first-line chemotherapy. Compassionate and honest communication about prognosis and likelihood of benefit from treatment may help to close the gap between hope and expectation and enable patients to make fully informed decisions about palliative chemotherapy.

Development of the cancer therapy satisfaction questionnaire: item generation and content validity testing

OBJECTIVES

This study was undertaken to develop a new questionnaire, the Cancer Therapy Satisfaction Questionnaire (CTSQ), to focus on the issues oncology patients consider when evaluating chemotherapy in terms of expectations and satisfaction.

METHODS

Items of the CTSQ were generated through the review of responses from interviews with oncology patients, physicians, and nurses. Analysis of the data was stratified by disease stage, disease type, and country to explore potential differences between these groups. Two rounds of face and content validity testing were then conducted.

RESULTS

Patients explained their hopes for efficacy and factors related to treatment satisfaction. Content validity testing in 30 patients, followed by additional testing in 10 patients on oral therapy, suggested that patients felt the questionnaire was clear, comprehensive, relevant, and easy to complete. Minor revisions were implemented to improve clarity, resulting in deletion of 12 items, modification of 17 items and the rewording of "chemotherapy" to "cancer therapy" to ensure patients on oral therapy were able to respond. The CTSQ contains 21 items and assesses seven domains: Expectations of cancer therapy, Feelings about side effects, Oral cancer therapy adherence, Convenience, Satisfaction with cancer therapy, Stopping cancer therapy, and Reasons for nonadherence.

CONCLUSIONS

The CTSQ was designed for adults with a wide range of cancer types and stages, receiving a variety of cancer treatment formulations. A validation study is currently underway to examine the psychometric properties, further refine the questionnaire and develop scoring methods for the CTSQ.

Considerations of healthcare professionals in medical decision-making about treatment for clinical end-stage cancer patients

In order to determine which considerations healthcare professionals use in decision-making about treatment for inpatients with end-stage cancer, we observed 110 discussions at multidisciplinary meetings at two oncology departments. The discussions concerned 74 patients. Thirty-three of the 110 discussions concerned potentially life-prolonging or life-shortening treatments. The most important decision-making considerations were chance of improvement, patient's treatment wishes, amount of suffering, and the chance of therapy being successful. Discussions resulted in 6 decisions that might shorten life, 10 decisions that might prolong life, and 23 postponements of decisions because of lack of information. These observations confirm that medical interventions with a possible life-prolonging or life-shortening effect are a frequently discussed issue in medical decision-making for end-stage cancer patients in The Netherlands. Before making a decision, healthcare professionals gather extensive information about what gain is to be expected from an intervention. When healthcare professionals establish that a decision would be medically appropriate, the patient's wish will often be an important consideration.

The experiences of district nurses caring for people receiving palliative chemotherapy

The treatment options being offered to people with advanced cancer are increasing with growing use of palliative chemotherapy. As people are experiencing shorter hospital stays and receiving treatment on an outpatient basis, this has implications for primary health-care provision. This study aimed to explore the experiences of district nurses caring for patients receiving palliative chemotherapy: how they viewed their role, factors that influenced their role and their attitudes to palliative chemotherapy. Data were collected using qualitative interviews that incorporated critical incident technique (n=10). Themes that emerged from the content analysis included the role of the district nurse, knowing the patient and family, the interface between hospital and primary care, and uncertain ground. District nurses saw their role as having relevance at all stages of the patient's cancer journey and the provision of holistic care based on good interpersonal relationships was valued. However, difficulties were perceived at the interface between hospital and primary care. District nurses had ambivalent attitudes to palliative chemotherapy but had positive attitudes towards optimizing quality of life and care in the palliative stages of illness.

Evidence-based follow-up of lung cancer patients

Evidence-based follow-up care of the lung cancer patient is straightforward with periodic histories and physical examinations recommended to detect recurrence. Yearly chest radiographs to detect second primaries "may be reasonable" in small and non-small cell lung cancer patients. The routine use of computed axial tomography (CAT) scans, bone scans, brain imaging, and serum tumor markers is not recommended in lung cancer patients. Many patients receive more extensive and expensive follow-up after treatment, despite the lack of curative options for recurrent lung cancer or evidence that earlier treatment of recurrence leads to better medical outcomes. The reasons for this are not known at present but could involve patient or physician preference, with no disincentives for extra testing. Adherence to breast cancer follow-up clinical practice guidelines at one cancer center reduced cost by one third with no change in health outcomes, but no studies have been performed in lung cancer.