Abstract
BackgroundCurrent guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Conventional cytotoxic agents are administered intravenously and have major life-threatening toxicities. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. MTAs are substantially more expensive, between £2-8 K per month, and perceived as easier to start than stop.MethodsA systematic review of decision-making concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on MTAs. Nine electronic databases searched. PRISMA guidelines followed.ResultsForty-two studies included. How are decisions made? Decision-making was shared and ongoing, including stopping, starting and trying different treatments. Oncologists often experienced ‘professional role dissonance’ between their self-perception as ‘treaters’, and talking about end of life care. Why are decisions made? Clinical factors: disease progression, worsening functional status, treatment side-effects. Non-clinical factors: physicians’ personal experience, values, emotions. Some patients continued treatment to maintain ‘hope’, often reflecting limited understanding of palliative goals. When are decisions made? Limited evidence reveals patients’ decisions based upon quality of life benefits. Clinicians found timing withdrawal particularly challenging. Who makes the decisions? Decisions were based within physician-patient interaction.ConclusionsOncologists report that decisions around stopping chemotherapy treatment are challenging, with limited evidence-based guidance outside of clinical trial protocols. The increasing availability of oral MTAs is transforming the management of incurable cancer; blurring boundaries between active treatment and palliative care. No studies specifically addressing decision-making around stopping MTAs in clinical practice were identified. There is a need to develop an evidence base to support physicians and patients with decision-making around the withdrawal of these high cost treatments.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-1862-0) contains supplementary material, which is available to authorized users.
Highlights
Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches
Recent research has demonstrated palliative cytotoxic chemotherapy at the end of life to be associated with a host of adverse outcomes including cardiopulmonary resuscitation, death in intensive care unit, place of death less likely to be at home or in preferred place and late hospice referral, as well as no survival benefit [10, 11]
Increased prescribing of cancer treatments over longer periods of time has been linked to availability of a plethora of new anti-cancer drugs, the molecular targeted anticancer agents (MTAs) such as small molecule kinase inhibitors (KIs) [12, 13]
Summary
Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. Increased prescribing of cancer treatments over longer periods of time has been linked to availability of a plethora of new anti-cancer drugs, the molecular targeted anticancer agents (MTAs) such as small molecule kinase inhibitors (KIs) [12, 13]. Kinase-inhibitors (KIs) have improved survival in traditionally chemoresistant cancers, including advanced non-small cell lung cancer (NSCLC) [17,18,19], melanoma [20, 21] and renal cell cancer [22, 23]
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