Because of their rigorous methodologic development, the measures of cancer care intensity described above have been endorsed by the National Quality Forum (NQF) as surveillance measures for end-of-life care, and were recommended for further development to be used for quality-improvement purposes. The Agency for Healthcare Research and Quality (AHRQ) is currently funding contracts to validate these specific measures further. They have also undergone testing in other health care settings and in other countries.7,8
One reason for this interest is that they have the relatively unique feature of assessing overuse. Oncologists have traditionally focused on underuse (surgery, adjuvant chemotherapy or radiation) as the source of most quality problems, with little attention to the possibility that overuse could result in poor quality care.
There is evidence that the use of chemotherapy near the end of life is not related to its likelihood of providing benefit.9
Indeed, we found in our analyses that the mean duration of the last treatment regimen, which is sometimes used as a proxy for time to progression, was stable at 61 days during the last decade, whereas overall chemotherapy utilization was increasing. This suggests that there was no increase in effectiveness of the chemotherapy being used, with patients mostly coming off treatment when restaged after approximately 2 months. So, why does overly aggressive care occur? In a survey of Medicare beneficiaries, observed geographic variation in end-of-life treatment could not be explained by patient preference,10
suggesting that physician practice style is a major driver.11
There are many rationales for recommending treatment with very limited potential benefits. For example, it can be seen as providing hope. Moreover, the discussion about changing the focus of treatment from fighting the cancer to providing symptomatic and supportive care is a difficult one that nobody relishes.12
It is often easier to recommend another line of chemotherapy. The issue can be complicated by oncologists’ anecdotal experiences of occasional patients who seemed to actually respond to late-line treatment, a concern that is becoming even more relevant now that relatively nontoxic targeted agents are altering the risk/benefit calculation. And lastly, there may be financial incentives. Jacobson et al13
explored whether physicians who were relatively more generously reimbursed for chemotherapy made different decisions in situations with substantial clinical discretion about whether to give treatment and which drugs to use, namely the management of metastatic common solid tumors. They found that reimbursement did not affect the decision to give chemotherapy or not, but once that decision was made, oncologists tended to use drugs for which they were reimbursed the most. For example, a $33 increase in reimbursement for carboplatin was associated with 17% higher utilization of that drug.
On the other hand, patients may request an aggressive treatment approach right to the end. They may not understand their true prognosis,14
have unrealistic expectations about the benefits of chemotherapy,15
want to be “a fighter,” or feel that doing something (anything) is better than doing nothing.16,17
Moreover, it has been shown many times that patients will accept much more toxicity for a smaller benefit than will providers.18
This observation is commonly put forward to suggest that physicians cannot make these treatment decisions for patients. It begs the question, however, of why oncologists agree to provide treatments to patients that they would not take themselves.19
By shepherding many patients through the journey towards death, oncologists have a broader perspective and experience than their patients can possibly have. Consequently, oncologists must be prepared to tell patients when they would be better off without the next line of possible chemotherapy.20