End-of-life care

End-of-life chemo risks unwanted deaths in hospital

Chemotherapy is still given to a minority of patients as part of their end-of-life care despite concerns about the risk of toxicity and hospitalisation that can impact quality of life, Australian research shows.

A retrospective analysis of data from the Queensland Oncology Repository found about 9% of patients with lung cancer and about 12% of patients with pancreatic cancer received chemotherapy in the last 30 days of their lives.

The study, published in the Internal Medicine Journal, comprised 16,501 lung cancer deaths and 4,144 pancreatic cancer deaths between 2005 and 2014.

It found in both cancer types, chemotherapy was more likely to be administered in younger patients, males versus females, where there were distant metastases, those living in urban areas compared to rural areas, and those from an area of higher socioeconomic status.

In lung cancer patients, those with a Carlton Comorbidity Index greater than zero were less likely to receive chemotherapy (p<0.001).

In pancreatic cancer patients, chemotherapy was more common in non-Indigenous compared to Indigenous patients.

Lung and pancreatic cancer deaths most commonly occurred in hospitals (83% and 81% respectively) with more than a third of deaths in acute care wards (37% and 36%).

Deaths after end-of-life (EOL) chemotherapy were significantly more likely to occur in an acute care facility when compared to all deaths in both cancer groups.

There was no evidence of difference in EOL chemotherapy administration between public and private hospitals for lung cancer but private patients with pancreatic cancer were more likely to receive chemotherapy than public patients.

“Despite an ever increasing list of potential therapeutics options it is imperative that chemotherapy prescribing towards EOL is driven by measurable indicators such as performance status rather than financial incentives or clinician and/or patient emotional decision-making,” the study said.

The study team said their observed prevalence of chemotherapy at end of life was similar to other Australian data but lower than international studies.

“This observed rate suggests timely discontinuation of chemotherapy and transition to best-supportive and palliative care is occurring, and earlier than in other countries.”

Importantly, end-of-life chemotherapy increased the risk of patients dying in hospital, and in an acute care ward versus palliative care.

“The prevalence increased from 37% for all lung cancer deaths to 60% with EOL chemotherapy, and 36% to 53% respectively for pancreatic cancer,” the study said.

The investigators, including Associate Professor Euan Walpole from the Division of Cancer Services at the Princess Alexandra Hospital in Brisbane, said clear evidence exists supporting the discontinuation of systemic therapy in the terminal phase of life.

“Further chemotherapy is in turn associated with increased treatment-related toxicity and increased hospitalisation which opposes patient preferences to avoid death in an acute care facility.”

They said that as well as the impact on a patient’s quality of life, chemotherapy and hospitalisation remain two of the largest cost areas in cancer care.

“Treatment choices that minimise unnecessary hospitalisation therefore also offer some of the best opportunities to reduce health care costs.”

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