Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort studyBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1219 (Published 04 March 2014) Cite this as: BMJ 2014;348:g1219
- Alexi A Wright, assistant professor of medicine1,
- Baohui Zhang, research statistician2,
- Nancy L Keating, associate professor of medicine and health care policy3,
- Jane C Weeks, professor of medicine1,
- Holly G Prigerson, professor of medicine2
- 1Harvard Medical School, Department of Medical Oncology, Dana-Farber Cancer Institute, Dana 1133, 450 Brookline Avenue, Boston, MA 02215, USA
- 2Center for End-of-Life Research, Weill Cornell Medical College, New York, NY 10065, USA
- 3Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115, USA
- Correspondence to: H G Prigerson
- Accepted 27 January 2014
Objectives To determine whether the receipt of chemotherapy among terminally ill cancer patients months before death was associated with patients’ subsequent intensive medical care and place of death.
Design Secondary analysis of a prospective, multi-institution, longitudinal study of patients with advanced cancer.
Setting Eight outpatient oncology clinics in the United States.
Participants 386 adult patients with metastatic cancers refractory to at least one chemotherapy regimen, whom physicians identified as terminally ill at study enrollment and who subsequently died.
Main outcome measures Primary outcomes: intensive medical care (cardiopulmonary resuscitation, mechanical ventilation, or both) in the last week of life and patients’ place of death (for example, intensive care unit). Secondary outcomes: survival, late hospice referrals (≤1 week before death), and dying in preferred place of death.
Results 216 (56%) of 386 terminally ill cancer patients were receiving palliative chemotherapy at study enrollment, a median of 4.0 months before death. After propensity score weighted adjustment, use of chemotherapy at enrollment was associated with higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) and late hospice referrals (54% v 37%; 13.6%, 3.6% to 23.6%) but no difference in survival (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). Patients receiving palliative chemotherapy were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; −10.8%, −1.0% to −20.6%), compared with those who were not. Patients receiving palliative chemotherapy were also less likely to die in their preferred place, compared with those who were not (65% v 80%; adjusted risk difference −9.4%, −0.8% to −18.1%).
Conclusions The use of chemotherapy in terminally ill cancer patients in the last months of life was associated with an increased risk of undergoing cardiopulmonary resuscitation, mechanical ventilation or both and of dying in an intensive care unit. Future research should determine the mechanisms by which palliative chemotherapy affects end of life outcomes and patients’ attainment of their goals.
Contributors: AAW and HGP were responsible for the study concept and design. AAW, HGP BZ, NLK, and JCW analyzed and interpreted the data. AAW drafted the manuscript and all authors revised it for important intellectual content. AAW, BZ, NLK, and HGP approved the final manuscript, had full access to all of the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. HGP is the guarantor.
Funding: HGP has received research grants MH63892 from the National Institute of Mental Health and CA 106370 and CA 156732 from the National Cancer Institute; AAW has received research grants 1K07 CA166210 from the National Cancer Institute and MRSG-13-013 from the American Cancer Society and a Conquer Cancer Foundation of American Society for Clinical Oncology Career Development Award; NLK received research grant 1R01 CA164021 from the National Cancer Institute. The funding organizations had no role in the design and conduct of the study; collection, analysis, or preparation of the data; or preparation, review, or approval of the manuscript. Any opinions, findings, and conclusions expressed in this material are those of the authors and do not necessarily reflect those of the American Cancer Society, the American Society of Clinical Oncology, or the Conquer Cancer Foundation.
Competing interests: All authors have completed the ICJME uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: HGP has received research grants from the National Institute of Mental Health and the National Cancer Institute; AAW has received research grants from the National Cancer Institute and the American Cancer Society and a Conquer Cancer Foundation of American Society for Clinical Oncology Career Development Award; NLK received a research grant from the National Cancer Institute; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influence the submitted work.
Ethical approval: The study received approval from the human subjects committees of all participating centers. All patients gave written informed consent.
Transparency declaration: HGP affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
Data sharing: Specific assessments, statistical code, and the dataset are available on request from the corresponding author at.
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