Chemotherapy or Palliative Care: How Should the Decision Be Made?

One dilemma medical oncologists face is deciding whether someone should receive chemotherapy. In a patient with advanced cancer, when should cancer treatments such as chemotherapy stop and palliative care begin? Doctors working in oncology clearly feel substantial pressure from patients and relatives on this issue, which should be specifically addressed in oncology training. But do we have a tool that can provide stronger evidence-based answers to “chemotherapy or palliative care” beyond intuition?

A notable study on this subject was published by Lindsay Renfro and colleagues in 2017 in the Journal Of Clinical Oncology . These researchers developed a tool predicting which of our patients with advanced colorectal cancer are at greatest risk of early death. This draws on a database of almost 23.000 patients available to ARCAD, a large collaborative trial group. They used a multivariable logistic regression model to determine which factors could develop an algorithm identifying patients at risk of death within 90 days after diagnosis or presentation to an oncology clinic.

It is unsurprising that the factors include age, number of metastases , general performance status, body mass index (the lower the BMI, the higher the probability of death), and BRAF status. A high neutrophil count, hemoglobin, and platelet count, among other factors, may also indicate an inflammatory picture; elevated bilirubin (jaundice) is also among the factors increasing risk.

Related topics:

• Let Us All Avoid Overtreatment in Cancer That May Cause Death!
• What Is General Performance Status for a Cancer Patient?

For example, consider a man at least 70 or in his early 80s with advanced colon cancer, a general performance score of 2, numerous metastatic sites, a BRAF-mutant tumor, a high neutrophil count, and thrombocytopenia. Calculating his variables with this tool gives an approximately 90-day probability of death of % 50.

After such a result, should we offer intensive chemotherapy despite poor general condition and potential treatment adverse effects? In a situation with no chance of complete cure, appropriately explaining to the patient and relative that chemotherapy’s potential benefit is relatively small and directing the patient to palliative care aimed at easing distress appears the better option.