When Chemotherapy Makes You Feel Worse

Chemotherapy is a common treatment at many stages and kinds of cancer. Although it has been proved to prolong life significantly and sometimes cure the disease, sometimes, according to a study published last month in JAMA Oncology, it does more harm than good.

The study, which was accompanied by an editorial, called into question the common practice of giving chemotherapy to people with solid tumors who are deemed to be terminal and expected to live no longer than six months.

Anybody with common sense, it seems to us, would wonder why such patients are ever prescribed such therapy, which often carries terrible side effects. As Holly Prigerson, director of the Cornell Center for Research on End-of-Life Care told NPR, “Chemotherapy is not meant to cure people like that.”

The reason they do get this treatment, according to the story, is in the hope that it will extend their lives even a little, or make them more comfortable. Also, said Prigerson, lead author of the study, “I think some patients would say, ‘I don’t care, I want to be on chemotherapy; it gives me something to do and it makes me feel that I’m fighting my cancer,’ That’s fine, if patients know that the likelihood of them benefiting from that chemotherapy is still remote, and it will probably make them feel sicker because of toxicities and side effects of the treatment.”

Indeed. Chemotherapy, which uses chemicals with a specific toxic effect on cancer-producing microorganisms, is a systemic treatment. That means the drugs, which are administered via an IV, flow through the bloodstream throughout the body. Although they’re intended to selectively destroy cancerous tissue, they are powerful toxic agents that, according to the National Cancer Institute, can cause a range of side effects, depending on the individual. Some people have few problems, but often there are many, or some that are particularly awful – anemia, bleeding and bruising, diarrhea, constipation, hair loss, cognitive problems, nausea and vomiting, nerve problems and more.

Prigerson’s team wanted to study whether chemotherapy for patients with advanced cancer who wanted to prolong or improve their life actually realized such benefit from the treatment. They interviewed patients’ caregivers to find out how the patients fared during the final week of life.

“They assessed things like their mood, how anxious they were, their physical symptoms and their overall quality of life,” Prigerson said. They found that chemotherapy often harmed them, reduced their quality of life and failed to extend it.

That was true even for patients who were feeling relatively OK, and had been active when the new round of chemotherapy began.

“The conventional wisdom,” Prigerson acknowledged, “is that patients and oncologists think, ‘Why not? I have nothing to lose.’ And I think the wake-up call from these data, really, is to say, ‘There are harms being done, and there is a cost to getting chemo so late.’ ”

These situations are part and parcel of the desperation many people – providers, patients, caregivers – feel at the end of life, but, as we’ve often written, that instinct usually leads only to overtreatment and more despair, not anything positive.

Some people will always want more treatment, despite their prognosis, but it’s the caregivers’ obligation, as difficult as it is, not to encourage this approach to cancer care. Dr. Charles Blanke, an oncologist at the Knight Cancer Institute of the Oregon Health and Science University who co-wrote the JAMA editorial, told NPR, “I think this paper strongly argues that giving chemotherapy near the end of life – that is in patients with terminal cancer – should not be the default, and oncologists should have a darn good reason if they want to do so.”

The editorial by Blanke and Dr. Erik Fromme, an internist and palliative care specialist, called for changing this accepted medical practice. They wrote that “equating treatment with hope is inappropriate.”

“If the doctor really doesn’t expect you to be around in six months, it’s probably better to focus your time on something that’s not chemotherapy,” Blanke told NPR. His approach is palliative – that is, he focuses on pain relief, mood issues, sleep disturbances and other quality-of-life issues.

But the medical industrial complex is a slow-moving machine, and Dr. Lowell Schnipper, an oncologist who helped draft treatment guidelines at the American Society of Clinical Oncology, was cautious about overriding patient desires.

Patients should be told when their situation is truly dire, but he said each patient is different, and sometimes it’s worth trying this therapy.

Still, he acknowledged the importance of quality-of-life issues, and told NPR, “That is actually an important gap in our research knowledge, and this paper might actually be a step toward filling that gap.”

As we wrote a couple months ago, Medicare providers now are compensated for discussing end-of-life issues, and this acknowledgment of its importance might spur oncologists to rearrange their priorities, and help patients understand why chemotherapy sometimes is a terrible idea.

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