I hesitated before answering. Oncologists are always willing to recommend one more method of treatment to our patients, even if the chances of success are low.
Even a sad joke: “Why are coffins nailed?” He asked a question. The answer: “To keep oncologists from giving another round of chemotherapy.”
This unfortunate notion is unfortunately backed up by data. in An analysis In the year Between 2011 and 2020, 39 percent of patients diagnosed with cancer at one of the 280 cancer clinics in the United States died within 30 days of death and 17 percent received cancer treatment within two weeks of death, no decline in those rates since 2015. Until 2019
My patient was diagnosed with leukemia five years ago, and initially, after chemotherapy, the cancer went into remission. He and his parents were farmers from Latin America who moved to the US at the time to focus on medicine. When the leukemia returned a year later, a bone-marrow transplant was performed, and that seemed to do the trick, at least for a while.
But then a few years later it reared its ugly head, and we did more chemotherapy and another transplant to kill it.
Although that victory was short-lived, and several rounds of unsuccessful treatment later, here we were. The last course reduced his blood count, he was admitted to the hospital with an illness, which he did not survive.
Does it help patients live longer or better?
If we are benefiting our patients by helping them live longer or better, then giving chemotherapy toward the end of life is appropriate. This is our hope, but often it is not.
Other studies have shown that cancer patients who receive treatment at the end of life have a higher risk of death He entered the hospital And even in the intensive care unit, they are less likely to survive Important purposes: care They discussed with their health care team worse quality And Duration of life.
Recognizing this, the Centers for Medicare and Medicaid Services identified that administering chemotherapy within two weeks of death is a quality indicator that negatively affects payments to hospitals. Because of this, cancer doctors avoid giving treatment to patients at the end of life, and for doing so, they can cause problems with hospital administrators.
Although it is a measure of CMS, the percentage of patients treated at the end of life in the last three years Not much has changed.a recent study proved exactly that. Increase in treated patients.
Why do we do it? Maybe optimism is part of our nature, and that is what attracts us to the oncology profession. I focus on the positive, and that can really help my patients. Other studies have shown that optimism is associated with a better outlook for people with cancer Quality of lifeAnd in fact Long survival.
And perhaps chemotherapy is close to humanity’s last days on earth, and the CMS quality measure is biased and careless about the facts of how doctors and patients make decisions.
I looked into the eyes of my young patient and then into the eyes of his father, who was about my age. He looks kind, with a thick, bushy white beard, a red plaid shirt, and work jeans. This man honored the boy by accompanying him to every appointment and always linked my right hand to both of them, thanking him for the medical service – I felt unworthy to receive him because I was not able to eradicate the child’s blood cancer.
If our roles were reversed, how would I react if my son’s cancer doctor told me that, given the less than 10 percent chance CMS says that an additional chemotherapy option is off the table?
Don’t I want the doctor to pursue any and all means necessary to save my child’s life? Patients often do, and studies show that patients whose cancer has returned Very willing To receive less toxic cancer treatments.
We discussed giving another round of chemotherapy, although I told my patient and his family that I didn’t want to administer it because of the very small chance it would help. We also discussed my patient’s enrollment in a clinical trial of an experimental drug. And finally, we talked about palliative care and hospice, my preferred future.
“You’ve given us a lot to think about,” my patient told me as he and his family got up to leave. His father came to me and held my hand warmly as usual.
But a few days later, although he seemed fine in the clinic, my patient developed an infection that landed him in the intensive care unit. If I had given him chemotherapy, we would have blamed the treatment for the hospitalization.
But the cause is related to the underlying cancer, which is more susceptible to infection due to compromised immunity. At this point my patient was sick enough and decided enough was enough and received palliative care.
For many of my end-of-life patients who insist on that “one more round” of chemotherapy, hospitalization convinces them that the side effects of the treatment are not worth it. It is not surprising that people die immediately after the last treatment and stay in the hospital.
Giving people cancer chemotherapy when it’s futile just to say “we tried something” isn’t fair. That’s what the CMS Quality Score is trying to prevent. But in doing so, it should not interfere with the patient’s ability to come to that decision themselves.
Michael A. Secares, MD, is Chief of the Division of Hematology and Professor of Medicine at the Sylvester Comprehensive Cancer Center, University of Miami. He is the author of “Drugs and the FDA: Safety, Efficacy, and Public Trust.” Follow him on X @MikkaelSekeres.