Tumorspezifische Therapien in der Palliativmedizin

Abstract

Anticancer therapies (ACT) gain increasing attention and discussion in specialized palliative care institutions. Frequency, indication, mode of therapy, attitude of team members, and clinical outcome of these therapies implemented in specialized palliative care settings are still under investigation. Methods: The Hospice and Palliative Care Evaluation HOPE (15.03.-15.06.07) collected data from institutions treating in- and outpatients from a palliative care perspective, i.e. in, palliative medicine, hospice care and oncology, concerning the use of ACT. Furthermore, the clinical courses of all patients receiving chemotherapy on our specialized palliative care unit (PCU) have been reviewed critically (1999-2006). Results: 67 PCU, 8 oncology wards (OW), 24 inpatient hospices (IH), 28 practitioners and specialists (P&S) and 22 home care teams (HCT) contributed to HOPE 2007. 247 ACT have been documented for 3184 patients (7,8%)). Tumor therapy implied i.v. cytotoxic chemotherapy in 43,7%. Except from inpatient hospices, all types of institutions were engaged in ACT. During the observational period, 22,3% of all patients with documented ACT died, as compared to 31,18% deaths in the general study population. Under PCU and HCT surveillance, more patients died during the observational period (24,4% PCU resp. 27,3% HCT), as compared to oncological settings (8,7% OW resp. 11,9% P&S), with or without ACT documantation. On PCU, anticancer therapies were mainly indicated for symptom control reasons (38,38%), as compared to intended tumor regression (24,0%), contrary to OW (28,6% resp. 38,1%). Institutional teams showed a high level of agreement towards treatment decisions; 5,6% dissensual decisions were documented primarily in context with ACT intended for symptom control. At our PCU, 11 chemotherapies could be reviewed within 8 years. Significant treatment related morbidity occurred in 4/11 patients, including 1 fatal complication. In 5/11 patients chemotherapy was performed up to 3 weeks before death. The prospective evaluation of 10 patients showed profound symptom control in 2 cases, to be weighted against substantial expenses. Discussion: ACT are increasingly incorporated into palliative care institutions, implying substancial challenges for the competencies of specialized PCU. Patients receiving ACT differ from other palliative care patients, and patients under oncological surveillance show distinguishing features as compared to specialized palliative care institutions in terms of survival, functional status, team attitude and decision making. Therefore, conceptual questions regarding patient selection and palliative care treatment offers require further exploration.