Doctors are reporting a disturbing rise in the number of cancer patients getting chemo and other aggressive but futile treatment in the last days of their lives.
Critics of the practice say doctors should be concentrating instead on helping these patients die with dignity and in comfort, perhaps in a hospice.
Nearly 12 percent of cancer patients who died in 1999 received chemotherapy in the last two weeks of life, a large review of Medicare records revealed. That is up from nearly 10 percent in 1993, and the percentage probably is even higher today, researchers said.
"Patients don't like to give up," and neither do physicians, said Dr. Roy Herbst, a cancer specialist at the University of Texas' M.D. Anderson Cancer Center in Houston who had no role in the study.
Overly aggressive treatment gives false hope and puts people through grueling and costly ordeals when there is no chance of a cure, cancer specialists said.
"There is a time to stop," said Dr. Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical School. "It's sometimes easier to just keep giving chemotherapy than to have a frank discussion about hospice and palliative care."
Earle led the federally funded study and presented the findings Friday at a meeting in Atlanta of the American Society of Clinical Oncology.
He examined Medicare records on the care of 215,488 people who died of cancer in the 1990s.
Admissions to hospital intensive care units in the last month of life climbed from nearly 8 percent in 1993 to 11 percent in 1999. Emergency room visits rose from about 24 percent to more than 28 percent.
The number of cancer patients entering hospice in the last three days of life also rose, from roughly 12 percent to 15 percent.
"That's like a waste of the whole hospice process," which stresses preparing the patient emotionally and physically for death, Herbst said. "People have to be ready to do that."
Not knowing when death is imminent
Part of the problem is that doctors cannot predict how soon an individual patient will die, even when they know the cancer has spread widely and is incurable.
The study found variations around the country in how aggressive doctors were, but researchers would not give specifics.
This study focused on traditional chemotherapy and was done before newer medicines like Herceptin, Avastin and Gleevec, which more precisely target cancer, came into wide use.
"They're clearly not as toxic as the chemotherapy," so a patient's quality of life may not be harmed by late treatment with these drugs, Earle said.
Still, Ellen Stovall, president of the National Coalition for Cancer Survivorship, said doctors and patients have to be more realistic.
"I see, in cancer care, so much treatment being used in the last three months of somebody's life that doesn't really help," she said.
Not enough care for some
However, another study presented at the cancer meeting on Friday showed the opposite problem: people not getting enough care.
A survey of nearly 700 primary care doctors in Wisconsin found that only 11 percent would refer a patient with advanced lung cancer to a cancer specialist and only 25 percent would refer a woman with advanced breast cancer.
"We also found a general lack of knowledge about the benefits of newer treatments" that can help such patients, said Dr. Timothy Wassenaar of the University of Wisconsin-Madison, who reported on the study at the cancer meeting.
"That's horrible," Herbst said of the unwillingness to refer such patients. He noted that newer chemotherapy treatments have extended lung cancer survival from 20 percent at one year to nearly 50 percent now.
Dr. Sandra Horning, a Stanford University cancer specialist who is president of the oncology group, said the good news is that doctors in the survey were not influenced by whether a lung cancer patient had smoked. The notion that smokers bring the disease on themselves should not interfere with treatment, she said.