Re: Palliative care from diagnosis to death
The WHO resolution referred to by Murray et al recommends early introduction of palliative care. In the case of metastatic cancer, this remains uncommon unless poor physical performance contraindicates drug therapy. As the authors state, there is evidence that early palliative, 'best supportive care' or BSC (my preferred term) benefits both quality and quantity of life, even if used alone in metastatic cancer1. Indeed, there is considerable evidence that patients are inadequately empowered and poorly informed about the extreme rarity of cure when treated with cancer drugs2 , together with poor survival benefits (mostly in months), a high incidence of severe adverse effects and an increased risk of dying in hospital, even in intensive care .
Both patient and oncologist create unnecessary and unjustified momentum to initiate chemotherapy, sometimes also because of the latter’s conflicts of interest3. What is only rarely done is involvement of the palliative care physician at the time that treatment policy is discussed. Jointly advised by oncologist and palliative care physician – BSC alone might be a better choice in many cases. In my recent article on the ethics of cancer drugs4, I reviewed the frequently poor results of cancer drug therapy and the lack of empowerment of poorly-informed patients5. Until better drugs become available, a more balanced and informed multidisciplinary input, already at the time that treatment is being discussed should result in more ethical practice – more BSC alone in acknowledged poorly-responsive cancers, with a major consequent saving in medication costs for metastatic disease: now the commonest cause of death in many population groups. Such an approach is currently being evaluated by Dr JS Temel and colleagues at the Dana Farber Cancer Institute in Boston and similar studies in Europe are much overdue.
1. Bauman JR, Temel JS. The integration of early palliative care with oncology care: the time has come for a new tradition. J Natl Compr Canc Network 2014;12:1763-71
2. Koedoot CG, Oort FJ, de Haan RJ, Bakker PJ, de Graeff A, de Haes JC. The content and amount of information given by medical oncologists when telling patients with advanced cancer what their treatment options are: palliative chemotherapy and watchful-waiting. Eur J Cancer 2004;40:225-35.
3. Malin JL, Weeks JC, Potosky AL, Hornbrook MC, Keating NL. Medical oncologists’ perceptions of financial incentives in cancer care. J Clin Oncol2013;31:530-5
4. Wise PH. Cancer drugs, survival, and ethics BMJ 2016; 355
5. Gattellari M, Voigt KJ, Butow PN, Tattersall MH. When the treatment goal is not cure: are cancer patients equipped to make informed decisions? J Clin Oncol2002;20:503-13
Competing interests: No competing interests