Skip to main content

Advertisement

SpringerLink
Log in

The limit of therapies in oncology

  • Invited Paper
  • Published:
Journal of Medicine and the Person

Abstract

The appropriate role of antitumour therapies in far advanced cancer patients is a complex issue and the switch to best supportive care alone is often a difficult choice as there are no international guidelines on the minimum amount of benefit needed to justify the use of palliative chemotherapy. New chemotherapeutic drugs with well-tolerated toxic profiles are increasingly available and patients’ expectations often influence physicians to continue chemotherapy in the absence of a clear appropriateness principle, even when death is approaching. Recruitment in phase I studies is an opportunity to offer a potential, albeit rare, benefit when no other therapeutic options are available. Although communication and understanding between the physician, patient and family is pivotal to avoid futile care in cancer, modern clinicians often find themselves in difficulty when having to inform patients about a poor prognosis, mainly because they are all too aware of the poor accuracy of predictions about life-expectancy. Several tools on prognosis prediction are now available to help physicians discriminate between patients who could benefit from palliative chemotherapy and those for whom supportive and palliative approaches would be more suitable. It has also been seen that the management of patients with far advanced cancers is improved by close collaboration between palliative care experts and oncologists.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Harrington SE, Smith TJ (2006) The role of chemotherapy at the end of life: “when is enough, enough?”. JAMA 299:2667–2678

    Article  Google Scholar 

  2. Mooney GH (1980) Cost-benefit analysis and medical ethics. J Med Ethics 6:177–179

    Article  CAS  PubMed  Google Scholar 

  3. National Cancer Policy Board (1999) Ensuring quality cancer care. In: Hewitt M, Simone JV (eds) National Academy Press, Washington, DC

  4. Earle CC, Park ER, Lai B et al (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21:1133–1138

    Article  PubMed  Google Scholar 

  5. Earle CC, Neville BA, Landrum MB et al (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315–321

    Article  PubMed  Google Scholar 

  6. Earle CC, Landrum MB, Souza JM et al (2008) Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol 26:3860–3866

    Article  PubMed  Google Scholar 

  7. Tang ST, Wu SC, Hung YN et al (2009) Determinants of aggressive end-of-life care for Taiwanese cancer decedents, 2001 to 2006. J Clin Oncol 27:4613–4618

    Article  PubMed  Google Scholar 

  8. Hashimoto K, Yonemori K, Katsumata N et al (2009) Factors that affect the duration of the interval between the completion of palliative chemotherapy and death. Oncologist 14:752–759

    Article  PubMed  Google Scholar 

  9. Kao S, Shafiq J, Vardy J, Adams D (2009) Use of chemotherapy at end of life in oncology patients. Ann Oncol 20:1555–1559

    Article  CAS  PubMed  Google Scholar 

  10. Martoni AA, Tanneberger S, Mutri V (2007) Cancer chemotherapy near the end of life: the time has come to set guidelines for its appropriate use. Tumori 93:417–422

    PubMed  Google Scholar 

  11. Barbera L, Paszat L, Chartier C (2006) Indicators of poor quality end-of-life cancer care. J Palliat Care 22:12–17

    PubMed  Google Scholar 

  12. Emanuel EJ, Young-Xu Y, Levinsky NG et al (2003) Chemotherapy use among Medicare beneficiaries at the end of life. Ann Intern Med 138:639–643

    PubMed  Google Scholar 

  13. Murillo JR Jr, Koeller J (2006) Chemotherapy given near the end of life by community oncologists for advanced non-small cell lung cancer. Oncologist 11:1095–1099

    Article  PubMed  Google Scholar 

  14. Asola R, Huhtala H, Holli K (2006) Intensity of diagnostic and treatment activities during the end of life of patients with advanced breast cancer. Breast Cancer Res Treat 100:77–82

    Article  CAS  PubMed  Google Scholar 

  15. Riechelmann RP, Krzyzanowska MK, Zimmermann C (2009) Futile medication use in terminally ill cancer patients. Support Care Cancer 17:745–748

    Article  PubMed  Google Scholar 

  16. Matsuyama R, Reddy S, Smith TJ (2006) Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 24:3490–3496

    Article  PubMed  Google Scholar 

  17. Buckman R (1992) How to break bad news: a guide for health care professionals. Johns Hopkins Press, Baltimore

    Google Scholar 

  18. Gattellari M, Voigt KJ, Butow PN, Tattersall MH (2002) When the treatment goal is not cure: are cancer patients equipped to make informed decisions? J Clin Oncol 20:503–513

    Article  PubMed  Google Scholar 

  19. Hagerty RG, Butow PN, Ellis PA et al (2004) Cancer patient preferences for communication of prognosis in the metastatic setting. J Clin Oncol 22:1721–1730

    Article  PubMed  Google Scholar 

  20. Jecker NS, Pearlman RA (1992) Medical futility. Who decides? Arch Intern Med 152:1140–1144

    Article  CAS  PubMed  Google Scholar 

  21. Von Gruenigen VE, Daly BJ (2005) Futility: clinical decision at the end-of-life in women with ovarian cancer. Gynecol Oncol 97:638–644

    Article  Google Scholar 

  22. Trevena LJ, Davey HM, Barratt A et al (2006) A systematic review on communicating with patients about evidence. J Eval Clin Pract 12:13–23

    Article  PubMed  Google Scholar 

  23. Finlay E, Lu HL, Henderson H et al (2009) Do phase I patients have greater needs for palliative care compared with other cancer patients? Cancer 115:446–453

    Article  PubMed  Google Scholar 

  24. Glare P, Sinclair C, Downing M et al (2008) Predicting survival in patients with advanced disease. Eur J Cancer 44:1146–1156

    Article  PubMed  Google Scholar 

  25. Chow E, Harth T, Hruby G et al (2001) How accurate are physicians’ clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review. Clin Oncol 13:209–218

    CAS  Google Scholar 

  26. Viganò A, Dorgan M, Bruera E, Suarez-Almazor ME (1999) The relative accuracy of the clinical estimation of the duration of life for patients with end of life cancer. Cancer 86:170–176

    Article  PubMed  Google Scholar 

  27. Knaus WA, Harrell FE Jr, Lynn J et al (1995) The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 122:191–203

    CAS  PubMed  Google Scholar 

  28. Evans C, McCarthy M (1985) Prognostic uncertainty in terminal care: can the Karnofsky index help? Lancet 1:1204–1206

    Article  CAS  PubMed  Google Scholar 

  29. Llobera J, Esteva M, Rifà J et al (2000) Terminal cancer. duration and prediction of survival time. Eur J Cancer 36:2036–2043

    Article  CAS  PubMed  Google Scholar 

  30. Maltoni M, Caraceni A, Brunelli C et al (2005) Prognostic factors in advanced cancer patients: evidence-based clinical recommendations—a study by the Steering Committee of the European Association for Palliative Care. J Clin Oncol 23:6240–6248

    Article  PubMed  Google Scholar 

  31. Lau F, Cloutier-Fisher D, Kuziemsky C et al (2007) A systematic review of prognostic tools for estimating survival time in palliative care. J Palliat Care 23:93–112

    PubMed  Google Scholar 

  32. Maltoni M, Tassinari D (2004) Prognostic assessment in terminally ill cancer patients: from evidence-based knowledge to a patient–physician relationship and back. Palliat Med 18:77–79

    Article  PubMed  Google Scholar 

  33. Pirovano M, Maltoni M, Nanni O et al (1999) A new palliative prognostic score: a first step for the staging of terminally ill cancer patients. Italian Multicentric and Study Group on Palliative Care. J Pain Symptom Manage 17:231–239

    Article  CAS  PubMed  Google Scholar 

  34. Maltoni M, Nanni O, Pirovano M et al (1999) Successful validation of the palliative prognostic score in terminally ill cancer patients. Italian Multicenter Study Group on Palliative Care. J Pain Symptom Manage 17:240–247

    Article  CAS  PubMed  Google Scholar 

  35. Tassinari D, Montanari L, Maltoni M et al (2008) The palliative prognostic score and survival in patients with advanced solid tumors receiving chemotherapy. Support Care Cancer 16:359–370

    Article  PubMed  Google Scholar 

  36. Morita T, Tsunoda J, Inoue S (1999) The palliative prognostic index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 7:128–133

    Article  CAS  PubMed  Google Scholar 

  37. Chuang RB, Hu WY, Chiu TY (2004) Prediction of survival in terminal cancer patients in Taiwan: constructing a prognostic scale. J Pain Symptom Manage 28:115–122

    Article  PubMed  Google Scholar 

  38. Agrawal M, Emanuel EJ (2003) Ethics of phase I oncology studies: reexamining the arguments and data. JAMA 290:1075–1082

    Article  PubMed  Google Scholar 

  39. Casarett DJ, Karlawish JH, Henry MI, Hirschman KB (2002) Must patients with advanced cancer choose between a Phase I trial and hospice? Cancer 95:1601–1604

    Article  PubMed  Google Scholar 

  40. Finlay E, Casarett D (2009) Making difficult discussions easier: using prognosis to facilitate transitions to hospice. CA Cancer J Clin 59:250–263

    Article  PubMed  Google Scholar 

  41. Decoster G, Stein G, Holdener EE (1990) Responses and toxic deaths in phase I clinical trials. Ann Oncol 1:175–181

    CAS  PubMed  Google Scholar 

  42. Estey E, Hoth D, Simon R et al (1986) Therapeutic response in phase I trials of antineoplastic agents. Cancer Treat Rep 70:1105–1115

    CAS  PubMed  Google Scholar 

  43. Rodenhuis S, van den Heuvel WJ, Annyas AA et al (1984) Patient motivation and informed consent in a phase I study of an anticancer agent. Eur J Cancer Clin Oncol 20:457–462

    Google Scholar 

  44. Tomamichel M, Sessa C, Herzig S et al (1995) Informed consent for phase I studies: evaluation of quantity and quality of information provided to patients. Ann Oncol 6:363–369

    Google Scholar 

  45. Itoh K, Sasaki Y, Fujii H et al (1997) Patients in phase I trials of anti-cancer agents in Japan: motivation, comprehension and expectations. Br J Cancer 76:107–113

    Google Scholar 

  46. Yoder LH, O’Rourke TJ, Etnyre A et al (1997) Expectations and experiences of patients with cancer participating in phase I clinical trials. Oncol Nurs Forum 24:891–896

    Google Scholar 

  47. Hutchinson C (1998) Phase I trials in cancer patients: participants’ perceptions. Eur J Cancer Care 7:15–22

    Google Scholar 

  48. Cheng JD, Hitt J, Koczwara B et al (2000) Impact of quality of life on patient expectations regarding phase I clinical trials. J Clin Oncol 18:421–428

    Google Scholar 

  49. Daugherty CK, Banik DM, Janish L, Ratain MJ (2000) Quantitative analysis of ethical issues in phase I trials: a survey interview of 144 advanced cancer patients. IRB 22:6–14

    Google Scholar 

  50. Schutta KM, Burnett CB (2000) Factors that influence a patient’s decision to participate in a phase I cancer clinical trial. Oncol Nurs Forum 27:1435–1438

    Google Scholar 

  51. Joffe S, Cook EF, Cleary PD et al (2001) Quality of informed consent in cancer clinical trials: a cross-sectional survey. Lancet 358:1772–1777

    Google Scholar 

  52. Moore S (2001) A need to try everything: patient participation in phase I trials. J Adv Nurs 33:738–747

    Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Unità Operativa di Biostatistica e Sperimentazioni Cliniche, I.R.S.T., Via P. Maroncelli 40, 47014, Meldola, FC, Italy

    O. Nanni & E. Scarpi

Authors
  1. O. Nanni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Scarpi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to O. Nanni.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nanni, O., Scarpi, E. The limit of therapies in oncology. J Med Pers 8, 112–120 (2010). https://doi.org/10.1007/s12682-010-0062-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12682-010-0062-6

Keywords

Search

Navigation