Chemotherapy Interventions
      All interventions need to be individualized and reflect the goals of an informed patient. Patients who enroll in the hospice program 'early' may still be receiving active chemotherapy. There are many palliative chemotherapy regimens or hormal therapies that may improve the quality of life of incurable patients and would not be inappropriate within hospice. Often a trial of steroids (e.g. Decadron) may benefit many patients.
     Other considerations: 
some general studies on palliative chemotherapy:

Palliative chemotherapy for non-small cell lung cancer.

Adelstein DJ.   Semin Oncol 1995 Apr;22(2 Suppl 3):35-9

The results of several randomized trials suggest a marginal survival benefit for patients with metastatic non-small cell lung cancer after treatment with chemotherapy. Toxicity, cost, and inconvenience have led many physicians to question whether chemotherapy has even a palliative role in this disease. Furthermore, it is well established that patients with a poor performance status, who are most in need of symptomatic palliation, are also those who are least likely to benefit and most likely to experience treatment-related toxicity. Nonetheless, evidence of a symptomatic benefit from combination chemotherapy has been presented. Indeed, symptomatic palliation can result even in the absence of a conventionally defined chemotherapy-induced response.

Quality of life during chemotherapy in non-small cell lung cancer patients.

Fernandez C.   Acta Oncol 1989;28(1):29-33

After chemotherapy 17 of 19 patients (89%) gained weight; 20 presented anorexia, 10 of those (50%) improved; 15 had pain, 7 of those (47%) were alleviated; cough was reported in 22, in 10 (45%) it was ameliorated; hemoptysis disappeared in 10 of 11 patients (91%); of the 9 patients who had dyspnea, 7 improved (78%); and astenia was attenuated in 8 of 16 patients (50%). Quality of life was reported improved in 75% of those patients who had considered themselves seriously affected prior to the treatment

Supportive care versus supportive care and combination chemotherapy in metastatic non-small cell lung cancer. Does chemotherapy make a difference?

Ganz PA.  Cancer 1989 Apr 1;63(7):1271-8

Current chemotherapy treatment of metastatic non-small cell lung cancer has demonstrated some objective responses, but is still largely palliative. This report reviews the results of a randomized trial in patients with advanced metastatic non-small cell lung cancer which compared treatment with supportive care (treatment with palliative radiation, psychosocial support, analgesics, nutritional support) to supportive care plus combination chemotherapy with cisplatin and vinblastine. Although the patients receiving combination chemotherapy had a slightly longer median survival (20.43 weeks versus 13.57 weeks), it was not statistically significant (P = 0.09). In addition, the patients receiving chemotherapy experienced serious toxicity, and showed no significant benefit in terms of quality of life as measured by Karnofsky performance status score.

Clinical benefit from palliative chemotherapy in non-small-cell lung cancer extends to the elderly and those with poor prognostic factors.

Hickish T.    Br J Cancer 1998 Jul;78(1):28-33

When the independent factors for symptom response were used to group patients into prognostic categories, 30-48% of patients with an adverse set of factors had symptom relief. Similarly using the relative risk of death to subgroup the patient population, 54% of patients at high risk of death (greater than 8.0), with a median survival of 2.5 months, had symptom relief.  Additionally, older age is positively associated with objective response and the majority of patients with the worst prognosis have symptom relief from treatment with chemotherapy.

Patient preferences for treatment of metastatic breast cancer: a study of women with early-stage breast cancer.

McQuellon R.   J Clin Oncol 1995 Apr;13(4):858-68

The greater the toxicity potential of the treatment, the less likely patients were to accept the treatment, although approximately 15% of patients would prefer high-risk treatment for as little as 1 month of added life expectancy. Between 34% and 82% of patients would prefer different therapies for a 6-month addition to life expectancy, whereas almost all patients would accept treatment for a 5-year increase in length of survival. Moreover, 76% of patients would prefer standard treatment or an experimental agent to reduce symptoms or pain, even if such treatment did not prolong life.

Measuring health-related quality of life in clinical trials that evaluate the role of chemotherapy in cancer treatment.

Michael M.  CMAJ 1998 Jun 30;158(13):1727-34

Quality of life is a subjective multidimentional concept that can be assessed by means of validated questionnaires completed by patients.  Palliation implies improvement in either the duration or quality of life remaining.  A few large trials incorporating these principles have shown that chemotherapy can provide palliation for patients with advanced cancer.

Preferences for chemotherapy in patients with advanced non-small cell lung cancer: descriptive study based on scripted interviews.

Silvestri G.   BMJ 1998 Sep 19;317(7161):771-5

The minimum survival threshold for accepting the toxicity of chemotherapy varied widely in patients. Several patients would accept chemotherapy for a survival benefit of 1 week, while others would not choose chemotherapy even for a survival benefit of 24 months. The median survival threshold for accepting chemotherapy was 4.5 months for mild toxicity and 9 months for severe toxicity. When given the choice between supportive care and chemotherapy only 18 (22%) patients chose chemotherapy for a survival benefit of 3 months; 55 (68%) patients chose chemotherapy if it substantially reduced symptoms without prolonging life.

Gemcitabine: symptomatic benefit in advanced non-small cell lung cancer.

Thatcher N.   Semin Oncol 1997 Jun;24(3 Suppl 8):S8-6-S8-12

Recent studies have indicated that chemotherapy not only provides some survival benefit, but also reduces tumor-related symptoms and improves the performance status of patients receiving chemotherapy. Data from single-agent gemcitabine studies demonstrate improvements in a range of tumor symptoms, including cough, hemoptysis, pain, dyspnea, and anorexia, as well as increases in performance status. Indeed, more patients benefit from gemcitabine chemotherapy than suggested by the objective response rate.

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