Full-textDOI: · Available from: G Michael Downing, Aug 08, 2015
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Article: The limit of therapies in oncology[Show abstract] [Hide abstract]
ABSTRACT: The appropriate role of antitumour therapies in far advanced cancer patients is a complex issue and the switch to best supportive care alone is often a difficult choice as there are no international guidelines on the minimum amount of benefit needed to justify the use of palliative chemotherapy. New chemotherapeutic drugs with well-tolerated toxic profiles are increasingly available and patients’ expectations often influence physicians to continue chemotherapy in the absence of a clear appropriateness principle, even when death is approaching. Recruitment in phase I studies is an opportunity to offer a potential, albeit rare, benefit when no other therapeutic options are available. Although communication and understanding between the physician, patient and family is pivotal to avoid futile care in cancer, modern clinicians often find themselves in difficulty when having to inform patients about a poor prognosis, mainly because they are all too aware of the poor accuracy of predictions about life-expectancy. Several tools on prognosis prediction are now available to help physicians discriminate between patients who could benefit from palliative chemotherapy and those for whom supportive and palliative approaches would be more suitable. It has also been seen that the management of patients with far advanced cancers is improved by close collaboration between palliative care experts and oncologists. KeywordsPalliative care-Appropriateness of therapy-Prognosis12/2010; 8(3):112-120. DOI:10.1007/s12682-010-0062-6
- South Dakota journal of medicine 01/2008; Spec No.:54-8.
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ABSTRACT: Prognostication is an important clinical skill for all clinicians, particularly those clinicians working with patients with advanced cancer. However, doctors can be hesitant about prognosticating without a fundamental understanding of how to formulate a prognosis more accurately and how to communicate the information with honesty and compassion. Irrespective of the underlying type of malignancy, most patients with advanced cancer experience a prolonged period of gradual decline (months/years) before a short phase of accelerated decline in the last month or two. The main indicators of this final phase are poor performance status, weight loss, symptoms such as anorexia, breathlessness or confusion and abnormalities on laboratory parameters (e.g. high white cell count, lymphopaenia, hyopalbuminaemia, elevated lactate dehydrogenase or C-reactive protein). The clinical estimate of survival remains a powerful independent prognostic indicator, often enhanced by experience, but research has only begun to understand the different biases affecting clinicians' estimates. More recent research has shown probabilistic predictions to be more accurate than temporal predictions. Simple, reliable and valid prognostic tools have been developed in recent years that can be used readily at the bedside of terminally ill cancer patients. The greatest accuracy occurs with the use of a combination of subjective prognostic judgements and objective validated tools. Communicating survival predictions is an important part of cancer care and guidelines exist for improving delivery of such information. Important cultural differences may influence communication strategies and should be recognised in clinical encounters. More well-designed studies of prognosis and its impact on decision making are needed. The benefits and limitations of prognostication should be considered in many clinical decisions.European Journal of Cancer 06/2008; 44(8):1146-56. DOI:10.1016/j.ejca.2008.02.030 · 4.82 Impact Factor