Is standard oncology care killing patients?

In 2010, the Temel article reported that early palliative
care prolongs survival in patients with Non-Small Cell Lung Cancer
(NSCLC). As a palliative care physician,
I would love to believe that excellent symptom control attention to patients’
goals of care would increase a patient’s quantity of life as well as quality of
life. However, I find it somewhat
implausible that palliative interventions would prolong life in patients with
NSCLC. What is the mechanism by which goals
of care discussions delay the progression of cancer? How do opioids and other symptom management
medications prolong life? Since the
basic finding was that patients randomized to early palliative care lived
longer than patients randomized to standard care, we must seriously consider
the conclusion that standard oncologic care is shortening life.

How might evidence-based, standard of care oncology
therapies that have been proven to prolong survival in randomized trials actually
shorten life? One possibility is that
oncology trials (like most trials) enroll younger, healthier patients than
standard oncology practice. We know that
patients who are older with greater comorbidities and functional impairment are
at higher risk of suffering the adverse effects of many treatments and less
likely to reap the benefits. Thus,
although the evidence may support the use of the standard chemotherapy in
younger patients, when extrapolated to older, multimorbid, real-world clinical
setting patients, the harms of the standard of care may have outweighed the
benefits.

The 2012 follow-up article entitled “Effect of early
palliative care on chemotherapy use and end-of-life care in patients with
metastatic NSCLC” (PMID 22203758) offers some additional information but leave
many questions unanswered. Authors showed that the overall number of
chemotherapy regimens did not differ between standard care and early palliative
care groups. More early palliative care
patients appeared to choose no chemotherapy but the differences were not
statistically significant. Further, more
early palliative care patients appeared to choose to receive 3^rd and
4^th line chemotherapy, but these differences were also not
statistically significant. Important
unanswered questions include, 1) was all first-line chemotherapy
identical? Did early palliative care
patients receive less toxic first-line chemotherapy than standard care
patients? 2) Is first-line chemotherapy defined as whatever regimen was
provided first, or could it have been the second regimen tried on a
patient? This may be one explanation of
why early palliative care patients had (non-statistically significant) greater
use of third- and fourth-line chemotherapy regimens. If these 3^rd and 4^th
line regimen were thought to have lower side effects, patients receiving early
palliative care may have chosen to utilize less toxic but potentially less
evidence-based 3^rd or 4^th line regimen.

The Temel study showed that early palliative care prolonged
survival compared to standard care. An
equivalent description of the results would be that standard care shortened
survival compared to early palliative care. Currently, we do not have enough data to determine which interpretation
is more valid. Hopefully, additional
data from this study will shed light on whether current standard care is being
inappropriately applied to older, sicker patients leading to shortened life.

by: Sei Lee