In older adults (≥70 years) with advanced or metastatic solid tumors, how does palliative chemotherapy compare to exclusive palliative care in terms of quality of life?

Palliative Chemotherapy vs. Exclusive Palliative Care in Older Adults with Advanced Cancer

In older adults (≥70 years) with advanced or metastatic solid tumors, palliative chemotherapy should be offered selectively as it does not consistently improve quality of life compared to exclusive palliative care, and may worsen quality of life near the end of life. 1

Decision-Making Framework

Patient Assessment Factors

1. Functional Status:

   • Assess Karnofsky Performance Status (KPS)
   • Evaluate for frailty and comorbidities that may increase toxicity risk

2. Disease Characteristics:

   • Tumor type and chemosensitivity
   • Expected response rates in elderly population
   • Disease burden and symptom profile

3. Patient Preferences:

   • Patient's goals of care (symptom control vs. life prolongation)
   • Treatment burden acceptability
   • Patient's values regarding quality vs. quantity of life 2

Evidence on Quality of Life Impact

Benefits of Palliative Chemotherapy

• May provide tumor response and symptom control in select patients
• Older adults can derive similar relative benefits as younger patients with certain chemotherapy regimens 1
• Can be appropriate for fit elderly patients with chemosensitive tumors

Drawbacks of Palliative Chemotherapy

• Increased risk of treatment-related toxicities in elderly patients 1
• Higher rates of hospitalization when primary dose reductions are used 3
• Chemotherapy within 60 days of death is associated with poorer quality of life 4
• Combination chemotherapy regimens produce only marginal increases in response rates with increased toxicity and no survival improvement 5

Optimizing Treatment Approach

When to Consider Palliative Chemotherapy

• Patient has good functional status
• Limited comorbidities
• Chemosensitive tumor type
• Significant symptom burden that may respond to treatment
• Patient values favor potential life extension even with treatment burden

When to Consider Exclusive Palliative Care

• Poor functional status
• Multiple comorbidities
• Chemoresistant tumor
• Prior poor response to treatment
• Patient values prioritize comfort and quality of life over length of life

Strategies to Improve Quality of Life During Treatment

If palliative chemotherapy is chosen:

• Consider single-agent regimens over combination therapy 5
• Implement early palliative care integration alongside chemotherapy 4
• Use stop-and-go or maintenance monotherapy strategies to minimize toxicity 1
• Avoid chemotherapy within 60 days of expected death 4
• Ensure timely transition to hospice care (ideally >1 week before death) 4

Common Pitfalls to Avoid

1. Overtreatment near end of life:

   • Continuing chemotherapy within 60 days of death worsens quality of life 4
   • Late hospice referrals reduce benefits of palliative care

2. Inappropriate dose modifications:

   • Primary dose reductions based solely on age may lead to higher hospitalization rates 3
   • Consider physiologic age rather than chronological age

3. Underestimating toxicity:

   • Older patients experience higher rates of treatment-related side effects 1, 6
   • Toxicities like nausea/vomiting and hematologic complications are consistently worse with combination chemotherapy 5

4. Neglecting patient preferences:

   • Patient treatment preferences are strongly influenced by their values regarding length vs. quality of life 2
   • Failure to address these values may lead to treatments misaligned with patient goals

Monitoring Quality of Life

• Regular assessment of symptom burden
• Evaluation of psychological distress (anxiety and depression) 6
• Ongoing discussion of goals of care
• Early transition to exclusive palliative care if quality of life deteriorates

By carefully selecting patients who may benefit from palliative chemotherapy and integrating early palliative care, clinicians can optimize quality of life for older adults with advanced cancer.