SAN FRANCISCOMore than four out of 10 cancer patients
received chemotherapy during their last year of life, according to a study of
Medicare patients in Massachusetts. Even a proportion of patients with tumors
considered unresponsive to chemotherapy received treatments within 1 month of
Ezekiel J. Emanuel, MD, PhD, chief of the Department of
Clinical Bioethics at the Clinical Center of the National Institutes of Health,
characterized the use of late-in-life chemotherapy as substantial and
surprising. It was also associated with increased medical costs of more than
$10,000. Surprisingly, patients receiving such chemotherapy were more likely to
be placed in hospice, he added, but for a shorter time than patients who had
not received chemotherapy.
"There’s widespread perception that oncologists
overtreat terminally ill cancer patients with chemotherapy. Oncologists usually
counter that use of chemotherapy is judicious, and they only give it where the
patient is likely to benefit or to improve the quality of life," said Dr.
Emanuel. He explained that the study was undertaken in the absence of data in
the literature to support either position.
He cautioned that the investigators relied on financial records
that presented no information about why chemotherapy was used. Among the many
possible explanations, he said, are uncertain prognosis, tumor responsiveness,
palliation, experimental chemotherapy, and patient and family demand for
Most Common for Hematologic Malignancies
Scientists from Harvard Medical School, Boston University
School of Medicine, and Harvard Vangard Medical Associates, all in
Massachusetts, joined in the study, which linked Health Care Financing
Administration (HCFA) files to 1996 death certificates from Massachusetts. They
found 34,131 death certificates for Medicare recipients, and tracked medical
bills for 7,919 people whose certificates listed cancer as the primary cause of
Dr. Emanuel reported that 41% of the cancer patients received
chemotherapy during the last year of life, 26% during the last 3 months, and
14% during the last month. Patients with hematologic malignancies were most
likely to receive chemotherapy; 58% received it during the last year, 45%
during the last 3 months, and 28% during the last month:
While chemotherapy was less common for patients with solid
tumors, Dr. Emanuel said the rates were similar for cancers known to respond to
chemotherapy and those that do not. Categorizing breast, colon, and ovarian
cancer as responsive to chemotherapy, Dr. Emanuel reported that 41% of colon
cancer patients received chemotherapy during the last 12 months of life, 26%
during the last 3 months, and 11% during the last month. For pancreatic cancer,
the rates were similar: 38%, 27%, and 14%, respectively. Yet pancreatic cancer
was classified as unresponsive along with renal cell, gall bladder, liver
cancers, and melanoma. Prostate and lung cancers were not placed in either
Duration of chemotherapy was less for the patients with cancers
in the unresponsive group. Among patients with responsive cancers, 62% received
more than 1 month of chemotherapy and more than 25% received 6 months. More
than 50% of patients with unresponsive cancers underwent chemotherapy for 1
month or less.
Age Also a Factor
Age also appeared to be factor. A higher proportion of younger
cancer patients had chemotherapy during the last year of life: 54% of patients
ages 65 to 74, 39% of those ages 75 to 84, and 23% of those 85 and over.
Similar proportions of male and female patients were reported: 43% vs 39%.
Costs were 32.5% higher for those who received chemotherapy
during the last year: $38,308 compared to $27,567 for those who did not. Dr.
Emanuel said the cost difference was higher for patients with
chemotherapy-responsive cancers than for those with cancers categorized as
unresponsive: 45% vs 20%. He suggested that patients with
chemotherapy-responsive cancers might have had higher costs because they
received more treatment and were more likely to be hospitalized.
"The relationship between use of chemotherapy and use of
hospice is complex," he continued. About one third of cancer patients
overall used hospice, but the proportion was higher among the patients who
received chemotherapy (38% vs 29%), and those who entered hospice after
chemotherapy used the service for a shorter time.
Dr. Emanuel offered a hypothesis for the relationship between
chemotherapy and hospice. "A simple rule is that users of medical services
are users of medical services and hospice is one additional medical
service," he said. "When you try chemotherapy and it doesn’t work,
hospice is the next thing that is done."
Deborah Schrag, MD, of Memorial Sloan-Kettering Cancer Center
in New York City, commented on the study. She said that standards are lacking
and controversial for what utilization rate represents appropriate use of
chemotherapy. "The question here," she said, "is, did the
doctors know these patients were terminally ill or not when they made these
decisions? And that we just can’t know because of the way this cohort was