Patients' perspectives on palliative chemotherapy of colorectal and non - colorectal cancer: a prospective study in a chemotherapy- experienced population.
ABSTRACT BACKGROUND: A better understanding of patients' views on the benefit and burden obtained from palliative chemotherapy would facilitate shared decision making. We evaluated palliative cancer patients' reported outcomes (PROs) for toxicity and investigated the survival threshold for which they would repeat chemotherapy (CTx). METHODS: Patients who had received a minimum of three months of palliative CTx for advanced colorectal (CRC) or non-colorectal (non-CRC: upper gastrointestinal, lung and head-and-neck) cancer were assessed by questionnaire. Patients were questioned about PROs for toxicity, subjective burden from side effects, and were asked for the survival threshold necessary for them to repeat CTx. Expected survival (sum of indicated survival threshold and median survival time with best supportive care) was compared to the patients' actual survival. RESULTS: One hundred and thirty-four patients (CRC: 58; non-CRC: 76) were surveyed. The most frequent PRO- grade 3/4 toxicities were acne (12.8%), fatigue (9.0%), and diarrhea (8.5%). The symptom causing the highest subjective burden was fatigue and was worse than expected in 29.9% of the patients. The median survival threshold for which patients would repeat CTx was significantly longer in CRC than in non-CRC patients (p=0.01). Median expected survival was significantly longer than actual median survival (CRC: 44.0 months [22.0-65.9] compared with 30.0 months of actual survival [20.9-39.1]; non-CRC: 22.0 months [15.3-28.6] compared with 19.0 months of actual survival [15.1-22.9], p=0.03). CONCLUSION: Fatigue deserves more attention when toxicity of treatment and symptoms of disease are explained to patients. Patients' survival expectations from palliative chemotherapy are higher than previously described, exceed the median survival time known from phase III trials, and are significantly longer than their actual survival.
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ABSTRACT: Initially unresectable colorectal liver metastases can be resected after response to chemotherapy. While cetuximab has been shown to increase response and resection rates, the survival outcome for this conversion strategy needs further evaluation. Patients with technically unresectable and/or ≥5 liver metastases were treated with FOLFOX/cetuximab (arm A) or FOLFIRI/cetuximab (arm B) and evaluated with regard to resectability every 2 months. Tumour response and secondary resection data have been reported previously. A final analysis of overall survival (OS) and progression-free survival (PFS) was performed in December 2012. Between December 2004 and March 2008, 56 patients were randomised to arm A, 55 to arm B. The median OS was 35.7 [95% CI: 27.2-44.2] months (arm A: 35.8 [95% CI: 28.1- 43.6], arm B: 29.0 [95% CI: 16.0-41.9] months, HR 1.03 [95% CI: 0.66-1.61], p=0.9). The median PFS was 10.8 [95% CI: 9.3-12.2] months (arm A: 11.2 [95% CI: 7.2-15.3], arm B: 10.5 [95% CI: 8.9-12.2] months, HR 1.18 [95% CI: 0.79-1.74], p=0.4). Patients who underwent R0 resection (n=36) achieved a better median OS (53.9 [95% CI: 35.9-71.9] months) than those who did not (21.9 [95% CI:17.1-26.7] months, p<0.001). The median disease-free survival for R0 resected patients was 9.9 [95% CI: 5.8-14.0] months, and the 5-year OS rate was 46.2 [95% CI: 29.5-62.9] %. This study confirms a favourable long-term survival for patients with initially suboptimal or unresectable colorectal liver metastases who respond to conversion therapy and undergo secondary resection. Both FOLFOX/FOLFIRI plus cetuximab, appear to be appropriate regimens for "conversion" treatment in patients with K-RAS codon 12/13/61 wild-type tumours. Thus, liver surgery can be considered curative or alternatively as an additional "line of therapy" in those patients who are not cured. NCT00153998, www.clinicaltrials.gov.Annals of Oncology 02/2014; · 6.58 Impact Factor
RESEARCH ARTICLEOpen Access
Patients’ perspectives on palliative chemotherapy
of colorectal and non - colorectal cancer: a
prospective study in a chemotherapy- experienced
Marika Mende1, Karolin Trautmann1, Anke Rentsch2, Beate Hornemann2,3, Ulrich S Schuler1,4,
Gerhard Ehninger1,2and Gunnar Folprecht1,2*
Background: A better understanding of patients’ views on the benefit and burden obtained from palliative
chemotherapy would facilitate shared decision making. We evaluated palliative cancer patients’ reported outcomes
(PROs) for toxicity and investigated the survival threshold for which they would repeat chemotherapy (CTx).
Methods: Patients who had received a minimum of three months of palliative CTx for advanced colorectal (CRC) or
non-colorectal (non-CRC: upper gastrointestinal, lung and head-and-neck) cancer were assessed by questionnaire.
Patients were questioned about PROs for toxicity, subjective burden from side effects, and were asked for the
survival threshold necessary for them to repeat CTx. Expected survival (sum of indicated survival threshold and
median survival time with best supportive care) was compared to the patients’ actual survival.
Results: One hundred and thirty-four patients (CRC: 58; non-CRC: 76) were surveyed. The most frequent PRO- grade
3/4 toxicities were acne (12.8%), fatigue (9.0%), and diarrhea (8.5%). The symptom causing the highest subjective
burden was fatigue and was worse than expected in 29.9% of the patients. The median survival threshold for which
patients would repeat CTx was significantly longer in CRC than in non-CRC patients (p=0.01). Median expected
survival was significantly longer than actual median survival (CRC: 44.0 months [22.0-65.9] compared with
30.0 months of actual survival [20.9-39.1]; non-CRC: 22.0 months [15.3-28.6] compared with 19.0 months of actual
survival [15.1-22.9], p=0.03).
Conclusion: Fatigue deserves more attention when toxicity of treatment and symptoms of disease are explained to
patients. Patients’ survival expectations from palliative chemotherapy are higher than previously described, exceed
the median survival time known from phase III trials, and are significantly longer than their actual survival.
Keywords: Chemotherapy, Palliative care, Survival threshold, Fatigue
Cancer rates are increasing worldwide with a predicted
incidence of 15 million cases in 2015 . Many cancer
patients are faced with incurable disease, requiring pallia-
tive therapy. In recent years, there has been a significant
improvement in overall survival with palliative chemo- and
antibody-based therapies in various malignancies, espe-
cially colorectal cancer [2-5]. In most clinical studies eva-
luating new cancer therapies, objective efficacy parameters
like overall and progression-free survival as well as safety
parameters are typical primary endpoints. In contrast,
so-called “PROs” (patient-reported outcomes), defining
subjective measures with the focus on patients’ perspec-
tives are less frequently investigated . Only a few studies
have explored patients’ attitudes toward therapy, particu-
larly in relation to survival benefit from chemotherapy
[7-14]. In the main, these studies indicated that cancer
* Correspondence: email@example.com
1Medical Department I, University Hospital Carl Gustav Carus, Fetscherstraße
74, 01307, Dresden, Germany
2University Cancer Center, University Hospital Carl Gustav Carus,
Fetscherstraße 74, 01307, Dresden, Germany
Full list of author information is available at the end of the article
© 2013 Mende et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Mende et al. BMC Cancer 2013, 13:66
patients accept toxic therapies for smaller survival benefits
than do healthy control groups, consisting of doctors,
nurses and volunteers [7-11]. As communication in pallia-
tive cancer care is challenging, a better understanding of
patients’ views on palliative chemotherapy would help to
facilitate shared decision making in such difficult treatment
situations . Here, we evaluated the subjective impact of
common chemotherapy-related side effects. We aimed to
find out the survival threshold at which palliative cancer
patients would consider chemotherapy worthwhile and
identified potential factors influencing the extent of the
indicated survival threshold. Patients’ survival expectations
were compared to their actual survival times.
The survey was conducted at our institution from August
2008 until December 2009. Patients who had completed a
minimum of three months of palliative chemotherapy for
colorectal cancer (CRC), cancer of the upper gastrointes-
tinal tract (u-GI), non-small cell lung cancer (NSCLC),
and squamous cell cancer of the head and neck (SCCHN)
were eligible. Patients were eligible independent of prior
cancer therapies including surgery, adjuvant chemo-, or
radiation therapy. The standard patient informed consent
for chemotherapy at the institution included an empha-
sised section describing the palliative aim of therapy.
Analysis was planned for two disease groups reflecting
their different prognoses: CRC versus non-CRC (u-GI,
NSCLC and SCCHN). Patients’ demographic and treat-
ment data, including age, gender, start of first palliative
therapy, current and prior regime as well as date of death
were acquired from the database of the Dresden University
Cancer Center. Treating physicians and nurses were
blinded to the results. All patients had given their informed
consent before inclusion into the study. The ethics commit-
tee of the University of Dresden approved the study.
The questionnaire was developed for the current study.
The questionnaire evaluated common chemotherapy-
related toxicities including stomatitis, nausea, vomiting,
diarrhea, fatigue, sensory neuropathy, acne, and alopecia
according to NCI-CT criteria  as well as pain .
Patients indicated the subjective burden from reported
toxicity on a numeric rating scale with a scale from 0 to
10. Choosing the number 0 would mean “no symptom”
and 10 would mean “worst possible symptom”. The inter-
pretation of the rating scales followed the interpretation of
the pain scale as described by Serlin (1-4 mild, 5-6 moder-
ate, 7-10 severe) . Additionally, patients were asked to
recall the severity of any toxicity compared with their ori-
ginal expectations after informed consent. For this
purpose they could choose between five different scenarios
according to a five-point Likert scale (“much less than
expected, less than expected, just as expected, more than
expected, much more than expected”) . Patients were
asked whether they would repeat therapy. Possible
answers included “probably yes, yes, unsure, probably no,
and no”. Finally, patients were requested to state the
survival threshold in months necessary for them to repeat
therapy. The “hospital anxiety and depression scale”
(HADS), a common screening method for anxiety disor-
ders (HADS-A) and depression (HADS-D) in physically ill
people was used to assess psychological morbidity [19,20].
The questionnaire was handed out by a cancer nurse at a
regular patient appointment and had to be returned in an
enclosed envelope. The original questionnaire can be
found in the Additional file 1: Figure S4.
The following two variables must be defined before fur-
ther explanation of analysis of the current descriptive
study: Survival threshold is the minimum survival bene-
fit in treatment. Expected survival is the sum of survival
threshold as stated by the patients and median survival
with best supportive care as reported in the literature.
Studies suggest a median survival with best supportive
care of eight months for CRC patients and of four
months for non-CRC patients [21-24].
Data were analyzed using SPSS version 17.0. Fre-
quency counts were conducted for descriptive analysis.
Bar charts summarize the frequency of chemotherapy-
related, patient-reported toxicities and the subjective
burden from toxicity as well as the extent of occurrence
of adverse events in comparison with expectation after
informed consent. Kaplan-Meier survival analysis was
performed to compare actual survival to expected sur-
vival for CRC and non-CRC patients. To determine the
influence of disease group, toxicity, pain, and psycho-
logical distress on the extent of the anticipated survival
threshold, multi-factorial ANOVA was done. P-values
less than 0.05 were considered statistically significant.
Between August 1st, 2008 and December 31st, 2009, 540
consecutive patients receiving chemotherapy at our insti-
tution were screened for the study as shown in Figure 1.
Two hundred and twenty-one patients were eligible but
87 patients did not participate or failed to respond. Of the
134 included patients, 58 patients suffered from CRC, 76
from non-CRC (u-GI: 45, NSCLC: 18, SCCHN: 13). The
median age was 63 years (range 32–86 years); 71.0% of the
patients were male. Patients had completed a median of
six months (range 3-51 months) of palliative chemother-
apy before entering the study. One hundred and six
patients (79.0%) had died by the end of follow-up in July
2011. Patients’ characteristics are summarized in Table 1.
Mende et al. BMC Cancer 2013, 13:66
Page 2 of 9
CRC patients were mainly treated with irinotecan- or
platinum- based therapies. Patients in the non-CRC group
received platinum- or gemcitabine-based therapies. In
both groups, therapy was usually a combination with a
second cytotoxic drug and/or a monoclonal antibody.
Platinum-containing therapy was more common in non-
CRC patients (54.0%) than in CRC patients (32.8%) at the
time of study (p=0.02). Ten patients in the non-CRC
group were only treated with tyrosine kinase inhibitors at
the time of the survey but had previously received at least
three months of conventional chemotherapy. For more
information about chemotherapy at the time of study and
prior to study see Additional file 1: Table S1B in the
Additional file 1.
A synopsis of patient-reported toxicity is shown in Figure 2
and Table 2 as well as in Additional file 1: Figure S2B. The
Excluded (n = 319)
Curative intention (n = 107)
Not eligible tumors (n = 111)
Palliative intention, but therapy less than 3 months (n = 94)
Lost to follow up (n = 7)
Eligible patients (n = 221)
Participants (n = 134)
No participation or no response (n = 87)
Assessed for eligibility (n = 540)
Figure 1 Flow diagram. Inclusion in the study.
Table 1 Patients’ characteristics
Median (Range)63 (32-78)61 (33-86) 62 (32-86)
IQR 58-68 54-67 55-68
< 60 yrs20 (34.0%) 35 (46.0%)1898 55 (41.0%)
60-69 yrs 28 (48.0%)27 (36.0%)2133 55 (41.0%)
≥ 70 yrs10 (17.0%) 14 (18.0%)662 24 (18.0%)
Male 45 (78.0%)50 (70.0%)2812 10 95 (71.0%)
Female 13 (22.0%) 26 (17.0%)1763 39 (29.0%)
Psychological Morbidity *
Anxiety 1 (2.0%)14 (18.0%)824 15 (11.0%)
Depression3 (5.0%) 13 (17.0%)832 16 (12.0%)
Median time of CTx8447 3,56
at survey (months)°
Number of deaths44 (76.0%)62 (82.0%)36 14 12106 (79.0%)
* Psychological morbidities (anxiety disorder, depression) measured by HADS, 131 responding patients.
° Median time of CTx at survey in months.
Mende et al. BMC Cancer 2013, 13:66
Page 3 of 9
most common toxicity of any PRO-grade was fatigue
(93.2%). Overall, the most frequently reported grade 3/4
acne was the most commonly reported grade 3/4 toxicity. In
non-CRC patients, fatigue was the most common toxicity.
Irrespective of disease group, patients felt severely burdened
by fatigue (14.3%), sensory neuropathy (12.0%), diarrhea
(11.1%), and nausea (9.8%). Whereas fatigue was the symp-
tom with the highest impact on non-CRC patients, CRC
patients felt especially burdened by diarrhea. In comparison
with patients’ expectations at informed consent, fatigue
occurred “more” and even “much more” than expected in
than initially expected were sensory neuropathy in 20.5% of
the patients and acne in 18.4% of the patients. Vomiting
A total of 130 patients completed the HADS section of
the questionnaire. Fifteen patients (11.5%) with possible
anxiety disorders were identified by HADS-A (CRC: 1;
non-CRC: 14; p=0.002). According to HADS-D, possible
depression occurred in 16 patients (12.3%; CRC: 3; non-
CRC: 13; p=0.056). Eight patients (CRC: 1; non-CRC: 7)
were likely to be affected by both, anxiety disorder and
depression. Patients in the non-CRC group were more
likely to show abnormal scores in any subscale of HADS,
compatible with psychological morbidity, than in the
A total of 131 out of 134 patients answered the question
whether they would repeat therapy. Eighty-eight percent
stated “yes” or “probably yes” while 9.0% were unsure,
and 3.0% responded “probably no” and “no”. Ninety-
seven patients (72.3%) answered the question concerning
the anticipated survival threshold. The following results
refer to these patients only. Answers varied from “even a
single day is worth it” (equivalent to zero months) up to
the expectation of a survival threshold of 340 months. In
summary, CRC patients considered a median threshold
of 36 months (95% CI: 24.0 to 60.0) to be worthwhile
repeating therapy for. For non-CRC patients, a median
survival threshold of 18 months (95% CI: 12.0 to 24.0)
would be necessary to repeat therapy. This difference
was statistically significant (p=0.01).
Expected vs. actual survival
After adding the median survival time with best support-
ive care to the patients’ stated survival thresholds, this
expected survival was plotted against the patients’ actual
survival as shown in Figure 3. In the CRC group, the
median expected survival was 44.0 months (95% CI: 22.0
to 65.9) compared with a median actual survival of
30.0 months (95% CI: 20.9 to 39.1). Non-CRC patients’
median expected survival was 22.0 months (95% CI: 15.3
to 28.6) compared with a median actual survival of
19.0 months (95% CI: 15.1 to 22.9). Expected survival
was significantly longer than the actual survival. (p=0.003;
adjusted for disease group).
Independent factors for magnitude of survival benefits
Multifactorial analysis suggested that disease group, de-
pression, and diarrhea were factors independently influ-
encing the extent of the anticipated survival threshold.
Non-CRC patients were willing to repeat therapy for
smaller survival thresholds than CRC patients. Patients
with higher scores in the HADS-D (equivalent to pos-
sible depression) and those with higher toxicity grades
for diarrhea would repeat therapy for a lower survival
threshold as well (Table 3).
Major goals of palliative chemotherapy are to improve
patients’ subjective well-being and to prolong survival.
Grade of PRO in
Toxicity comparison to
None Mild Moderate SevereMuch Less
Figure 2 PRO in toxicity for all patients. Green: All Patients.
* Patients’ expectations in comparison to informed consent: much
less, less, more, and much more than expected. † Grades of patient-
reported toxicity for alopecia are: none, grade 1, grade 2.
Mende et al. BMC Cancer 2013, 13:66
Page 4 of 9
In contrast to the latter, the patients’ perspectives on
benefits, toxicities and burden are less frequently studied
although important for decision making in several
aspects – the shared decision making of the patient with
his or her treating physician and the allocation of finan-
cial or other resources.
In our study population, acne, fatigue, and gastrointes-
tinal (GI) side effects were among the most frequently
PRO- grade 3/4 toxicity, with fatigue being the most se-
vere burden as reported by 14.3% of all patients. It is
known that skin and GI toxicity are typical grade 3/4
adverse events in multiple phase III chemotherapy trials
[5,25-27]. On the other hand, fatigue has rarely been
reported to be a major toxicity in such trials. This may
be because fatigue might be a symptom of the under-
lying malignant disease and therefore cannot be attribu-
ted to therapy alone [28,29]. It is known that 80.0% to
99.0% of patients undergoing chemotherapy report fa-
tigue at some point . Our study showed that fatigue
was worse than expected in one third of patients. These
findings are in agreement with data from Olver et al
, who compared patients’ pre-treatment expectations
Table 2 Quantitative analysis of PROs in toxicity
Grade of PRO in toxicity Entity
n= 57n= 75n=45n=18n=12
None 35.1%61.3% 66.7% 66.7%33.4%
Grade 1/254.4% 32.0% 31.1%27.8% 41.6%
Grade 3/410.5% 6.7%2.2%5.5% 25.0%
None44.4%21.4%18.2% 21.5% 33.4%
Grade 1/250.0%68.6% 72.8%71.4%50.0%
Grade 3/45.6% 10.0%9.0%7.1% 16.6%
None81.4% 75.7% 76.2%72.3% 77.0%
Grade 1/216.7%24.3% 23.8%27.7% 23.0%
None35.7% 62.1%54.6% 76.5%69.3%
Grade 1/250.0% 33.8%38.6% 23.5%30.7%
Grade 3/414.3%4.1% 6.8%0.0% 0.0%
Grade 1/287.7% 81.6% 75.6%94.4%84.6%
Grade 3/45.3% 11.8%17.7%0.0% 7.7%
None40.0%36.5% 31.9%41.2% 46.1%
Grade 3/4 15.5%10.6%2.2% 23.5%23.0%
Grade 212.5% 19.2%13.3%31.25% 25.0%
Sens. Neu. = Sensory Neuropathy.
Mende et al. BMC Cancer 2013, 13:66
Page 5 of 9
of toxicities with post-chemotherapy experiences. They
found that “feeling tired” was among the side effects that
occurred in more patients than was initially expected.
Interesting in this regard is the fact that fatigue is not
detailed on most commonly used consent forms .
We believe that fatigue deserves more attention when
toxicity of palliative treatment and symptoms of disease
are explained to the patient.
Overall, self-reported grade 3/4 toxicity and severe
burden rates remained relatively low. Patients seemed to
have been well informed about most adverse events
(apart from fatigue) prior to treatment. Expectations of
side effects were higher than their actual occurrence
which supports the findings in other studies .
The median actual overall survival in our study was
30.0 months in the CRC and 19.0 months in the non-
CRC group. This result exceeds the median overall sur-
vival observed in most phase III trials including meta-
static CRC and non-CRC cancer [2-5]. A length of time
bias together with the fact that we only included patients
who had already completed a minimum of three months
of palliative chemotherapy, possibly consistent with a
potential therapy benefit, may contribute to this finding.
In the current study, patients’ anticipated median sur-
vival thresholds were longer (CRC 36.0 months; non-CRC
18.0 months) than described in previous reports [7-11].
This might be influenced by the different surveying meth-
ods. Most prior studies used hypothetical situations and
classical time trade-off techniques where patients were
encouraged to choose between a given number of months,
time spans, or risk reduction they would consider a thresh-
old for therapy. In scenarios with mild toxicity, participants
would choose therapy for median benefits ranging from
1.5 months  to 4.5 months . For more intensive
treatment situations, expected survival benefits ranged
from 7.5 months  up to 12 months . The authors of
those studies concluded that patients were willing to
undergo treatment for small survival benefits. In contrast,
patients in our study were asked to state the exact survival
thresholds for which they would repeat chemotherapy.
Therefore discrepancies might reflect the difference be-
tween preferences in a hypothetical scenario and those in a
personally relevant clinical situation . The anticipated
survival threshold in our study varied widely (zero to
340 months) which confirms the fact that patients’ expec-
tations are extremely heterogeneous [8,11,33].
CRC: Expected survival
CRC: Actual survival
Non-CRC: Expected survival
Non-CRC: Actual survival
n = 97
Probability of survival (%)
04 8 12 24 36486072
Figure 3 Survival Expectation and Actual Survival. The figure shows actual survival (solid lines) and “expected survival” (dotted lines) of
patients with colorectal and non-colorectal solid tumours. Log-rank test combined for both strata: p = 0.003. Horizontal lines mark median
survival time with best supportive care known from studies. For CRC: Eight months. For Non-CRC: Four months. The patient-reported survival
threshold was added to median survival time with best supportive care.
Mende et al. BMC Cancer 2013, 13:66
Page 6 of 9
To our knowledge, this is the first study comparing
patients’ survival expectations with their actual survival.
Interestingly, the patients’ expected survival significantly
exceeded their actual survival time (p=0.003). In a study
by Brundage et al, the expectations of more than half of
the participants exceeded the estimated, realistic survival
benefit defined prior to survey . Chu et al found that
60.0% of their advanced NSCLC patients would prefer a
maximum extension of survival with the acceptance of
high toxicity . Additionally, in a Korean survey,
patients with metastatic solid cancers requested a two-
fold longer survival threshold than previous studies had
suggested . Similar to our findings of higher expecta-
tions in CRC patients, the recently published study of
Weeks and colleagues demonstrated that patients’
expectations from palliative chemotherapy are frequently
unrealistic and often even include cure .
Our results might have been biased by the construction
of the questionnaire used in the study. Patients were asked
about toxicity and burden from therapy first and then to
state the anticipated survival threshold. They might have
demanded higher thresholds from therapy after being
forced to recall toxicity. Conceivably, some patients might
have rather projected their wish for overall survival than
survival threshold. Furthermore, the patient group was
self-selecting as only 72.3% of the participants would an-
swer the survival threshold question at all. As our patient
population had completed a median time of six months of
therapy prior to study, which might be interpreted as evi-
dence of a therapy benefit, patients with rapid progression
or high levels of toxicity forcing an early discontinuance of
therapy might have had an entirely different view on sur-
vival threshold. Other patients might have been over-
whelmed by the question as it is known that many
palliative patients do not give any consideration to end-of-
life issues [35,36].
survival threshold were disease group, depression, and
diarrhea. As depression is known to be positively corre-
lated with hopelessness [37,38] this might be the explan-
ation why patients in our study with higher HADS-D
scores (possible depression) were more willing to repeat
therapy for lower thresholds than patients with lower
scores. Patients in the non-CRC group were more likely
to show abnormal scores in any subscale of HADS, com-
patible with psychological morbidity. This is in agree-
ment with a number of other studies showing that
cancer types with poor prognosis such as lung, pancre-
atic, or head and neck cancers are associated with the
highest rates of psychological distress [39,40]. As in sev-
eral other trials, gender [9-12] as well as previous ther-
apy experience  did not influence the anticipated
survival thresholds. The influence of age on anticipated
survival is controversial in the literature. Some authors
claim that older patients expect greater benefits [11,12].
Other studies as well as our own did not show any asso-
ciation between patient age and anticipated survival ben-
efits from palliative chemotherapy [10,13].
In conclusion, our data show that patients seem to be suffi-
ciently informed about possible adverse events during
chemotherapy as occurrence and extent were similar to
reported phase III trials. However, fatigue deserves more at-
tention when treatment and symptoms of disease are dis-
cussed with the patient. Patients’ expectations from survival
with palliative chemotherapy are higher than previously
described and exceed their actual survival. Even though
Table 3 Multi-factorial ANOVA
Independent factors Survival threshold
CRC vs. Non-CRC- 0.2890.032
Male vs. Female- 0.0130.921
< 60 vs. 60-69 vs. ≥ 70- 0.0540.638
None vs. Possible vs. Likely0.195 0.168
None vs. Possible vs. Likely- 0.4390.020
None vs. Grade 1/2 vs. Grade 3/40.2090.117
None vs. Grade 1/2 vs. Grade 3/4 0.1100.424
None vs. Grade 1/2 vs. Grade 3/4
None vs. Grade 1/2 vs. Grade 3/4 - 0.2670.032
None vs. Grade 1/2 vs. Grade 3/40.179 0.177
None vs. Grade 1/2 vs. Grade 3/40.2180.115
None vs. Grade 1/2 vs. Grade 3/4 0.1090.396
None vs. Grade 1 vs. Grade 2 0.107 0.404
None vs. Mild vs. Moderate vs.
Dependent factor: survival threshold; independent factors: disease group, age,
sex, psychological morbidity, toxicity, and pain.
Mende et al. BMC Cancer 2013, 13:66
Page 7 of 9
new therapies have achieved significant improvements in
overall survival, such expectations cannot be met yet. More
detailed discussions about survival benefits are necessary
prior to therapy  to facilitate shared decision making.
Additional file 1: Table S1B. Chemotherapy at time of study and prior
to study. Figure S2B. PROs in toxicity by disease group. Green: All
Patients, Red: CRC, Blue: Non-CRC. Figure S4. Questionnaire in German
with English translation.
G. Folprecht (not directly related to the current study):
Advisory boards: Merck KGaA, Roche, Bristol-Myes-Squibb
Study grants: Merck KGaA
Lecture honoraria: Merck KGaA, Roche, Novartis, Sanofi-Aventis, Amgen
All remaining authors have declared no conflict of interests.
MM: study design, data acquisition, data analysis and interpretation,
manuscript writing, KT: data analysis and interpretation, manuscript writing,
G. Ehninger: administrative support, study design, quality control of data and
algorithms AR: statistical analysis, quality control of data and algorithms, BH:
study design, data analysis and interpretation, U. S: study design, data
interpretation, quality control of data and algorithms, GF: study concepts and
design, data acquisition, analysis and interpretation, quality control of data
and algorithms, statistical analysis. All authors read and approved the final
Interim results of the current study were presented at 2011 ASCO
Gastrointestinal Cancers Symposium, January 20th- 23rd2011, San Francisco,
General Poster Session
1Medical Department I, University Hospital Carl Gustav Carus, Fetscherstraße
74, 01307, Dresden, Germany.2University Cancer Center, University Hospital
Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Germany.3Department
of Psychooncology, University Hospital Carl Gustav Carus, Fetscherstraße 74,
01307, Dresden, Germany.4Department of Palliative Care, University Hospital
Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Germany.
Received: 23 April 2012 Accepted: 30 January 2013
Published: 7 February 2013
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Cite this article as: Mende et al.: Patients’ perspectives on palliative
chemotherapy of colorectal and non - colorectal cancer: a prospective
study in a chemotherapy- experienced population. BMC Cancer 2013
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