Impact of Continuation of Chemotherapy in the Last Month of Life on Quality of Life and Health Services Utilization for Advanced Nsclc and Gastric Cancer Patients

The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. However, use of chemotherapy near EOL does not provide benefits to cancer patients, as evident by precipitating emergency room visiting, increasing intensive care unit care, precluding hospice discussion and early hospice referral, frequent deaths in an acute care hospital, a trend toward less satisfaction with care, and even a shorter survival. The rapidly escalating cost of palliative chemotherapy also adds expenditures to an already strained cancer care finance system. Therefore, overly aggressive chemotherapy use at EOL has been recognized as poor quality cancer care. However, few, if any research has been conducted on Taiwanese advanced cancer patients’ expectations and goals of palliative chemotherapy, especially for continuation of chemotherapy close to death, and treatment-related information received. Furthermore, the absolute benefits of chemotherapy on patient QOL are documented in the selected populations of formal clinical trials, which often include a highly selected population of patients, but whether such outcomes can be achieved in the unselected patient populations of everyday clinical practice is doubtful. Most importantly, the impact of continuation of chemotherapy close to death on patient QOL has never been explored both in Taiwan and worldwide. Therefore, the specific aims of this prospective, longitudinal study are to use advanced non-small cell lung cancer (NSCLC) and gastric cancer patients as a targeted population, to: (1) explore expectations/goals of palliative chemotherapy, (2) examine treatment-related information received, and (3) evaluate the impact of continuation of chemotherapy in the last month of life on QOL and healthcare services received at EOL. A prospective, longitudinal study will be conducted over three years using a propensity score (PS) matching technique on a convenience sample of 237 advanced NSCLC and gastric cancer patients to fulfill the aims of this study. Well-established instruments or questions from well-known published studies will be used to measure (1) expectations and goals of chemotherapy; (2) treatment-related information received; and (3) patient QOL (EORTC QLQ-C30, EORTC QLQ-LC13, and EORTC QLQ-STO 22). Assessments will be performed prospectively at an every-3-week schedule and continue until the patient dies or the patient can no longer be able to be interviewed. The patient expectations and goals about treatment and treatment-related information received only will be re-evaluated at each time of changes of treatment, including changes of chemotherapy regimens or treatment modalities. Within 2 to 3 weeks of a participant’s death, the medical record will be reviewed for medical care received in the patient’s last month of life and the causes and timing of using such healthcare services. Considering the lack of randomization inherent in the proposed observational study, a propensity-score matching technique (PS) will be used to balance characteristics that may significantly predispose advanced NSCLC and gastric cancer patients to receive chemotherapy or palliative care only in their last month of life. Logistic regression model using a generalized estimating equation (GEE) will be conducted on this PS matching population to examine longitudinal changes of and differences in expectations/goals of treatments, and treatment-related information received between patients in the continuation of chemotherapy group and those under palliative care only in their last month of life. Multivariate regression by the GEE will be used to evaluate the impact of continuation of chemotherapy in the patient’s last month of life on their QOL. Multivariate logistic regression analyses will be used to evaluate the impact of continuation of chemotherapy on healthcare services received at EOL and the causes for using such healthcare services. A better understanding of when in the cancer trajectory risk-taking preferences take priority over QOL preferences and where that transition point from valuing QOL in any degree over survival concern occurs and the reasons behind such decision-making will help advanced cancer patients through the EOL care decision- making process. Knowledge from the impact of continuation of chemotherapy in the last month of life on patient QOL can facilitate evaluation of whether the life extended by modern cancer treatment is enjoyable and valued by cancer patients. Understanding information received by advanced cancer patients regarding palliative chemotherapy can identify gaps between expected and realistic benefits that may achieve by chemotherapy. This information may highlight the future directions of clinical interventions to improve communication between patients, families, and healthcare providers to minimize over-estimated effectiveness of chemotherapy and to achieve EOL care that meets cancer patients’ needs and preferences.

Project ID:PC10301-1149
External Project ID:NSC101-2314-B182-025-MY3