Chemotherapy Use, Performance Status, and Quality of Life at the End of Life | Guidelines | JAMA Oncology | JAMA Network
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    2 Comments for this article
    Did chemotherapy affect QOL of final week ?
    Hideaki Takahashi | National Cancer Center Hospital East
    In their article, Holly G. Prigerson and their collegue argued that \"Among patients with good (ECOG score =1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOL near death.\"

    Authors showed baseline characteristics of all patients. But main result of this article was focused on the patients with good baseline performance status. In that case, baseline characteristics of the patients with good performance status should be shown. Were there any imbalance ? If so, Is there a possibility that the imbalance has affected the result.

    In another point of view. Authors assessed QOL at patients final week of
    life, but the timing of the last dose of chemotherapy was not shown. Were there any interval ? Is it reasonable to determined that chemotherapy affected QOL at patients final week of life?
    CONFLICT OF INTEREST: Corporate-sponsored research-<br/> Bayer Yakuhin<br/> Bristol-Myers Squibb<br/><br/>I recieved no support in this work.
    Improvements needed for study variables and analysis methods
    Cheryl D. Coon | Outcometrix
    I appreciate the efforts that went into conducting this sizable study at a delicate point in each of the participants’ lives, but I find the variables collected and the analysis approach lacking for the amount of press the conclusions are receiving. My main concerns are the variables collected and statistical methodology:

    1. While the observed variables were considered as confounding factors, some obvious variables were excluded that may explain or impact the results. In particular, time since diagnosis, time on treatment, and time from “baseline” to death would be informative covariates, as any one of these variables might explain the
    different patterns among ECOG groups. “Baseline” chemotherapy use alone is insufficient, as “baseline” is an arbitrary point in time and lacks the context of chemotherapy lines and duration prior to study enrollment. This study would have been more complete if the medical chart review had been expanded to obtain treatment history prior to enrollment or to confirm treatment status throughout the full study period.

    2. QOD was not assessed using a \"validated QOD measure\", as the cited reference includes no information about content validity (i.e., does the instrument measure the full breadth of concepts that are important to patients?) or construct validity (i.e., does the instrument measure the construct that it intends to measure?). The authors report the internal consistency of the three items, but this statistic alone is not sufficient evidence for the averaging of these items to create one score that is deemed QOD. QOL is a complex, multidimensional concept (e.g., Wilson and Cleary [1995]), and these study results hinge on an incomplete assessment of QOL, despite the existence of caregiver-reported QOL instruments in oncology with more thorough development and psychometric properties (e.g., Minaya et al., 2012).

    3. The use of a median split for dichotomizing the QOD measure is unclear and unwise. The authors claim that this was done “to facilitate analysis and interpretation”, but regression with continuous variables can be interpreted using similar language and is more powerful and precise than dichotomization (Uryniak, 2011). This cut-score has no inherent meaning, so the interpretation is actually misleading, as it groups patients without confirming with patients or caregivers that these scores are representative of high and low QOL. The authors did analyze the continuous QOD data, but this paper would benefit from making the continuous results available for readers to understand the distribution of QOD scores.

    While some of these concerns could be addressed with post-hoc analysis, many cannot, and I would encourage these authors and others to consider these points when designing future studies.

    Minaya P, et al. The CareGiver Oncology Quality of Life questionnaire (CarGOQoL): development and validation of an instrument to measure the quality of life of the caregivers of patients with cancer. Eur J Cancer. 2012;48(6):904-11.

    Uryniak T, et al. Responder Analyses—A PhRMA Position Paper. Stat Biopharm Res. 2011;3(3):476-87.

    Wilson, IB, Cleary, PD. Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. J Am Med Assoc. 1995;273(1):59-65.
    CONFLICT OF INTEREST: I have been employed as a consultant on clinical trials in oncology by Bristol Myers Squibb, Novartis, Pfizer, and Celgene.
    Original Investigation
    September 2015

    Chemotherapy Use, Performance Status, and Quality of Life at the End of Life

    Author Affiliations
    • 1Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, New York
    • 2Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
    • 3Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
    • 4Meyer Cancer Center of Weill Cornell Medical College, Medical Oncology/Solid Tumor Program, New York, New York
    • 5Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
    • 6Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
    • 7University of Michigan Comprehensive Cancer Center, Ann Arbor
    • 8James J. Peters VA Medical Center, Bronx, New York
    • 9Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
    • 10Department of Medicine, Medical Intensive Care Unit, New York Presbyterian Hospital-Weill Cornell Center, New York
    • 11Department of Medicine and Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
    • 12Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
    • 13Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
    • 14Department of Radiology, Weill Cornell Medical College, New York, New York
    JAMA Oncol. 2015;1(6):778-784. doi:10.1001/jamaoncol.2015.2378

    Importance  Although many patients with end-stage cancer are offered chemotherapy to improve quality of life (QOL), the association between chemotherapy and QOL amid progressive metastatic disease has not been well-studied. American Society for Clinical Oncology guidelines recommend palliative chemotherapy only for solid tumor patients with good performance status.

    Objective  To evaluate the association between chemotherapy use and QOL near death (QOD) as a function of patients’ performance status.

    Design, Setting, and Participants  A multi-institutional, longitudinal cohort study of patients with end-stage cancer recruited between September 2002 and February 2008. Chemotherapy use (n = 158 [50.6%]) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed at baseline (median = 3.8 months before death) and patients with progressive metastatic cancer (N = 312) following at least 1 chemotherapy regimen were followed prospectively until death at 6 outpatient oncology clinics in the United States.

    Main Outcomes and Measures  Patient QOD was determined using validated caregiver ratings of patients’ physical and mental distress in their final week.

    Results  Chemotherapy use was not associated with patient survival controlling for clinical setting and patients’ performance status. Among patients with good (ECOG score = 1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOD (odds ratio [OR], 0.35; 95% CI, 0.17-0.75; P = .01). Baseline chemotherapy use was not associated with QOD among patients with moderate (ECOG score = 2) baseline performance status (OR, 1.06; 95% CI, 0.51-2.21; P = .87) or poor (ECOG score = 3) baseline performance status (OR, 1.34; 95% CI, 0.46-3.89; P = .59).

    Conclusions and Relevance  Although palliative chemotherapy is used to improve QOL for patients with end-stage cancer, its use did not improve QOD for patients with moderate or poor performance status and worsened QOD for patients with good performance status. The QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death, even in patients with good performance status.