Radiation used inappropriately in terminal cancer

NEW YORK (Reuters Health) - Cancer doctors have a hard time estimating how long their terminal cancer patients will live, which often leads to inappropriate use of palliative treatments in the waning days of life, hints a study from Germany released today.

"The life span of cancer patients is overestimated by the doctors in the vast majority of cases," study chief Dr. Stephan Gripp, of University Hospital Dusseldorf, noted in an email to Reuters Health.

"Too optimistic estimates are dangerous for patients as they tempt doctors to apply prolonged irradiation schedules," he added, schedules that often are not completed because the patient dies or opts out of treatment.

For patients in the final stages of cancer, doctors will often give small doses of palliative radiation to help ease cancer-related pain and other symptoms. The goal is not to rid the patient of their cancer or even slow it down, but to provide a better quality of life in the final days of life.

But palliative radiation is not without side effects and for many it does little good near the end of life, according to the new study published online today in the journal Cancer.

Among 216 terminal cancer patients referred for palliative radiation between December 2003 and July 2004, 33 died within 30 days of admission to the radiation oncology department at University Hospital Dusseldorf. Most of them (91 percent) received palliative radiation treatment; half of them spent more than 60 percent of their remaining lifespan getting radiation.

The medical records showed that palliative radiation, which, in theory, should ease cancer symptoms, actually led to worsening symptoms in more than half of patients (52 percent). As a result, many prematurely discontinued radiation. "In our study," Gripp noted, "almost every second patient prematurely discontinued therapy. The extent of this problem was surprising to me. Single shot irradiation would have been a better choice in these patients."

Seven patients (23 percent) died during therapy. Only 26 percent of patients who got "palliative" radiation reported a reduction in pain. This suggests that a substantial number of terminally ill cancer patients do not benefit from palliative radiation, Gripp and colleagues say.

BETTER SURVIVAL ESTIMATES NEEDED

The study also suggests that cancer doctors need better methods for estimating survival time. In the current study, many doctors overestimated time left on earth. Survival was correctly estimated to be 30 days, at most, in only 16 percent of patients; one in five doctors incorrectly estimated that patients had more than 6 months to live.

This study illuminates the current limits of doctors' ability to predict death even when it is very close and to deliver effective "survival-time-adapted" pain-easing care, the researchers note.

When it comes to palliative treatment, an accurate estimate of how long a patient will live is important to avoid futile and costly treatment. "Many of our patients were treated with little or no benefit," the team reports, and "survival overestimates" may have contributed to inappropriate radiation therapy, "a considerable waste of time, and the high percentage of patients who discontinued therapy."

"By and large, the public and the medical profession presume that approaching death is discernible, put persuasive data are lacking," the researchers note. It's been suggested that for terminally ill patients, doctors generally tend to provide optimistic outlooks, and what they communicate to their patients is even more optimistic.

Better "objective" methods to more accurately gauge how long terminally ill patients will live are needed, Gripp and colleagues conclude. This will, hopefully, lead to more customized care.

In the meantime, are there things patients or family members could do to ensure appropriate palliative radiotherapy at the end of life? "I do not think so," Gripp said. "Realistic survival estimates (by medical professionals) are prerequisite to tailor palliative radiotherapy to the individual patient."

SOURCE: Cancer, online April 12, 2010.