Key findings
In many cases, chemotherapy is not appropriate treatment in the last 2 weeks of life. We took a look at this for the first time this year, and saw that the rate of chemotherapy use at the end of life varies quite a bit by patient age, by cancer type and by region. Further work is required to more fully understand treatment patterns and their interactions with the availability of palliative/end-of-life care services throughout Ontario.
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Goal |
| Chemotherapy in the last two weeks of life |
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What is chemotherapy?
Chemotherapy is a method of treating cancer using drugs either to prolong life or to increase quality of life by reducing a patient’s symptoms. A combination of different drugs is often used that is dependant on cancer stage, disease site and treatment intent.
What's new this year?
This is a new indicator reported for the first time in the CSQI 2009.
 Figure 1: Percentage of patients receiving chemotherapy in the last 2 weeks of life, Ontario, all cancers, by year of death (crude rate)
 Figure 2: Percentage of patients receiving chemotherapy in the last 2 weeks of life, all cancers, by LHIN (2002-2005)
 Figure 3: Percentage of patients receiving chemotherapy in the last 2 weeks of life, by age (2002-2005)
 Figure 4: Percentage of patients receiving chemotherapy in the last 2 weeks of life, by disease site (2002-2005)
 Figure 5: Percentage of patients receiving chemotherapy in the last 2 weeks of life, by disease site, by age (crude rate for 2002-2005)
What do the results show?
Use of chemotherapy in the last 2 weeks of life has remained fairly steady
Crude rates for chemotherapy in the last 2 weeks of life have remained steady since 2002 (Figure 1). Crude rates are not standardized for age and gender. When standardized, the overall rate for Ontario varies from approximately 4% to approximately 6%. Standardized rates are shown where appropriate (e.g., variation by LHIN). We don’t have an evidence-based target for this year, so we can’t tell whether 4%-6% is too high, too low, or about right.
Significant regional variability
Overall, we are seeing rates of chemotherapy use in the last 2 weeks of life of 6% (standardized rate shown in Figures 2 and 4), but the rate varies a great deal depending on region. This reflects fairly large differences in practice patterns. The lowest rates (2.4%) are in the South East Local Health Integration Network (LHIN) and the highest in the North West (9.3%) (Figure 2).
Younger patients are more likely to receive chemotherapy in the last 2 weeks of life
There are large differences in chemotherapy use according to age, with patients under 65 years of age being more than twice as likely to receive chemotherapy treatment within the last 2 weeks of life (Figure 3). This pattern is found across all cancer types with the exception of ovarian cancer, for which patients age 65 and older were more likely to receive chemotherapy in the last 2 weeks of life (Figure 5).
Variation by disease site in likelihood that chemotherapy is used in the last 2 weeks of life
Individuals with, for example, cancers of the central nervous system (CNS), head and neck, or prostate are less likely to receive chemotherapy in the last 2 weeks of life. This is in comparison with those with breast cancer, who are more likely to receive chemotherapy in the last 2 weeks of life. These variations are, in part, a reflection of decisions made based on the how different cancer types respond to chemotherapy (Figure 4). For example, the higher rate among leukemia and lymphoma patients (Figure 4) is appropriate according to experts. It reflects the toxicity of the chemotherapy regimen (combination of drugs) used with the intent to cure these diseases.
Why is this important to patient care?
Understanding treatment patterns helps patients and providers make more evidence-informed decisions
This is a baseline indicator presented for the first time in the CSQI to allow us to better understand treatment patterns at the end of life and to explore the appropriate use of chemotherapy along the patient continuum. Undoubtedly, some use of chemotherapy towards the end of life is appropriate, but we need to support patients and their providers to reduce its use when it doesn’t contribute to quality care. We think this can be done best by providing access to good end-of-life resources, by understanding the reasoning behind these treatment decisions, by researching best practice and by working to standardize the approach to care across the regions.
Availability of palliative care and other supportive resources affect the likelihood of treatment with chemotherapy in the last 2 weeks of life
Analyses of cancer patient data have shown that better availability of physician house visits, palliative care and home care resources is associated with a likelihood of a patient receiving chemotherapy in the last 2 weeks of life1,3. See End-of-Life Care.
Inappropriate use of chemotherapy has implications for quality of life
Quality of cancer care is most often measured by the degree to which effective practices are used, but the use of ineffective treatments is also an important measure of quality 1. There are several reasons why chemotherapy may be used in the last 2 weeks of a patient’s life. For example, patients whose cancer has responded to chemotherapy even in the late stages of the disease may receive chemotherapy as they approach the end of life. And those who cannot be cured may be offered late chemotherapy to prolong life or relieve their symptoms; the likelihood of this depends on the type of cancer and the condition of the patient 2. Because chemotherapy is so toxic, there is a risk that using it in the last 2 weeks of life may negatively impact the patient’s quality of life, or, in some cases, be the cause of death.
Late use of chemotherapy may also be requested by patients who have a poor understanding of their prognosis, have unrealistic expectations about the benefits of chemotherapy, or feel that continuing chemotherapy is better than taking no action 1. However, this raises the question of why physicians agree to provide treatments for which negative consequences might outweigh benefits. Some researchers note that recommending chemotherapy is a means of providing hope, and physicians may find it emotionally difficult to end chemotherapy in favour of palliative care 1,2. In general, physicians should recognize when patients are very near to death and stop aggressive care in favour of supportive treatment 3.
We need to understand these issues better. Clearly, having access to data with increased depth and breadth will help providers, healthcare professionals and the public gain a deeper understanding of the late use of chemotherapy in Ontario, and will provided information needed for policy and decision making about available resources. Patients and their families or caregivers need comprehensive information, adequate psychosocial support, and access to hospices, home care and other palliative care resources to minimize inappropriate use of chemotherapy and to ensure that the values and dignity of patients are respected.
How does Ontario compare?
Ontario rates of chemotherapy use in the last 2 weeks of life compare favourably with those found elsewhere. An analysis of Medicare patients in the U.S. who died of cancer, found that the percentage of patients receiving chemotherapy in the last 2 weeks of life rose continually from 1993-1999, and reached 11.6% in 1999. A recent study showed that 5.7% of patients who died of cancer in a Korean hospital in 2002 underwent chemotherapy within the last 2 weeks of life 4. A 2006 United Kingdom study found that during a 6 month period, of those receiving chemotherapy at a hospital in Surrey, 8% died within 30 days of chemotherapy 5.
What is being done?
Initiatives to improve palliative care under way
The Ontario Cancer Symptom Management Collaborative builds on the Provincial Palliative Care Integration Project and promotes integrated palliative care programs in every region. The collaborative facilitates changes in practice at the point of care to improve the patient experience. This includes promoting the use of common tools, earlier symptom control, better symptom management and coordinated palliative support. See Symptom Assessment.
The Provincial Palliative Care Program is developing recommendations on models of Palliative Care for the organization and delivery of palliative care treatment. These recommendations aim to increase accessibility to safe, equitable and quality palliative care that leads to the best outcomes for patients.
Through funding from HealthForceOntario and the 2008-2009 Interprofessional Care Education Fund, interprofessional primary healthcare teams working in the regions are being mentored to increase their knowledge of both collaborative practice and palliative care.
Notes
1 Earle CC, et al. Aggressiveness of cancer care near the end of life: Is it a quality-of-care issue? Journal of Clinical Oncology 2008; 26(23): 3860-3866.
2 Goncalves JF & Goyanes C. Use of chemotherapy at the end of life in a Portuguese oncology centre. Support Care Cancer 2008; 16: 321-327.
3 Barbera L et al. Indicators of poor quality end-of-life cancer care in Ontario. Journal of Palliative Care 2006; 22(1): 12-17.
4 Keam B, et al. Aggressiveness of cancer care near the end-of-life in Korea. Japanese Journal of Clinical Oncology 2008; 38(5): 381-386.
5 O'Brien M, Borthwick A, Rigg A, Leary A, Assersohn L, Last K, Tan S, Milan S, Tait D, Smith I. Mortality within 30 days of chemotherapy: a clinical governance benchmarking issue for oncology patients. British Journal of Cancer 2006; 95: 1632–1636
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