The present study investigated the situation of EOL chemotherapy and targeted therapy in patients at the end of life using consecutive data from 585 patients with advanced cancer who had died of cancer at our center. We showed that receipt of targeted therapy correlated with lower rates of admission to ICU compared with those who received palliative chemotherapy.
At the end of life, more detailed conversations between physicians and caregivers and patients could reduce the incidence of aggressive treatment, resulting in a significantly better QoL in the last month of life.11 However, for patients who are dying from advanced solid tumors, decision making in terms of treatment at the end of life is complex. Deciding upon a more aggressive intervention involves not only access to a hospice, but also the knowledge and attitude of the patient and their family toward hospices and palliative chemotherapy, and their relationship with primary and specialist physicians. Unfortunately, administrative data does not include these preferences.
Generally, certain physicians from cancer-specialty hospitals have studied palliative guidelines systematically. However, physicians can overestimate prognosis, often by at least 30%.12 Some physicians are from general hospitals and lack professional palliative knowledge, and it is difficult for many oncologists and caregivers to provide the option of stopping chemotherapy.13, 14 Hesitation regarding cessation of futile palliative chemotherapy might lead to more aggressive EOL care and life-sustaining treatment. In China, some caregivers ask physicians not to tell the truth concerning the patient’s condition, such that patients fail to receive the full picture regarding their disease and do not understand the purpose of palliative care, believing that their disease is curable.15 Patients have high expectations of palliative therapy and thus accept the adverse events and toxicity to prolong their survival.16 Previous studies found that patients would prefer to receive chemotherapy, even if it only prolonged their life for 1 week, because most patients do not receive enough information concerning the benefits of palliative chemotherapy. 17
Our study showed that in the last month of life, about 14.9% of patients received palliative chemotherapy, which is in line with international recommendations. However, a Portuguese study indicated that the prevalence of chemotherapy within the last month of life could be as high as 37%.18 One reason is that in more affluent countries, patients have a high chance of receiving medicalized death and futile treatments.19 Another explanation is that, at the end of life, older patients in China are more inclined to receive Chinese medicine rather than western medicine, which would affect the low proportion of chemotherapy use.
The results of the present study showed that younger patients (< 50 years old) with a PS<2 received more aggressive EOL chemotherapy and targeted therapy. There are several potential explanations for this. Patients younger than 50 years old were mostly better educated and tended to choose western medicine in preference to traditional Chinese medicine, which could explain why this subgroup were more likely to receive palliative chemotherapy. The younger patients also had lower rates of comorbidity and received more rounds of cytotoxic chemotherapy. There is a complex relationship between relationship aggressive care and comorbidity. Patients with comorbid conditions were less prone to receiving chemotherapy, and if they did receive it, they were more likely to be admitted to ICU or go to hospital in the final month of life.20
Admission to an ICU and receipt of CPR were more frequent among patients treated with palliative chemotherapy than in patients who received targeted therapy in the last month of life. Previously, the therapeutic options for patients with advanced cancer were limited to cytotoxic chemotherapy. Over the last decade, the treatment of patients with, for example, advanced NSCLC, has changed markedly. Successful therapies that target patients with anaplastic lymphoma kinase (ALK) rearrangements or epidermal growth factor receptor (EGFR) mutations have been developed.21-23 In cases where a specific oncogenic driver gene has been identified, most people choose targeted therapy. Thus, targeted therapy was used more often than traditional chemotherapy agents which often have lower toxicity and fewer complication, and our study results showed that patients who received targeted therapy received less aggressive treatment, such as ICU admissions and CPR treatment.
Every individual at the EOL has a right to pursue life prolongation at any cost. We cannot consider that their aggressive care is not necessary. However, mounting evidence suggests that the majority of dying patients do not desire such care.24-26 Research also suggests that less aggressive care is cheaper and less upsetting for surviving members of the patient’s family. 27-30 Accordingly, the arguments in favor of less aggressive EOL care suggest that discussions about changing EOL care should occur earlier to ensure that palliative treatment is consistent with the patient’s preferences.
Using these data as a starting point, we hypothesized that the adverse events or toxicity associated with intravenous chemotherapy outweigh its benefit over the whole course of treatment, especially toward the EOL. Considering the increasing availability of targeted therapy, we require a deeper understanding of their role at the EOL. In addition, we lack detailed knowledge about the factors that affect chemotherapy decision making at the EOL among physicians, patients, and their caregivers, such as, the effects of the values and beliefs of the patients and physicians, and discussion about decision making on the use of care at EOL. These factors will also contribute to the reason of their choice at EOL, for example emergency department visits, admission to an intensive care unit, increased hospital admission, or decreased hospice use. 31
Limitations
One limitation is the retrospective nature of this study, which relied on hospital records. A further limitation is that we did not analyze the role of targeted therapy at the EOL stage, which needs more research. In addition, a detailed analysis of the relationship between palliative chemotherapy and survival data of patients was not performed.