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Friday, January 3, 2014

Prostate Cancer: End-of-Life Care

Key findings

There is evidence that suggests that only some prostate cancer patients are accessing palliative and end-of-life treatment options that can improve their quality of life before death. More up-to-date data and a cohesive province-wide strategy are needed to support quality improvement initiatives in this area.

Palliative treatment and end-of-life care for prostate cancer patients with advanced disease

  • Cancer Care Ontario’s Prostate Cancer Treatment Pathway outlines Androgen Deprivation Therapy (ADT) or Androgen Suppression Therapy as the treatment of choice for advanced/metastatic prostate cancer patients.
  • The goal of using ADT is to reduce growth of cancer cells by reducing levels of male hormones, called androgens, in the body, or prevent them from reaching prostate cancer cells. Physicians monitor the PSA levels patients receiving hormone therapy assess progression of the disease.
  • In addition to ADT, chemotherapy and radiation are two viable options for metastatic prostate cancer patients. Docetaxel is a well-established chemotherapy drug. Treatment with chemotherapy drugs such as docetaxel can effectively treat patients with prostate cancers that do not respond to ADT and relieve pain in many cases1. Docetaxel has also been shown to improve survival in patients with metastatic disease. Not all patients with hormone refractory (castrate-resistant) disease are candidates for chemotherapy.
  • Radiation therapy plays an important role both in curing cancer and in controlling symptoms (palliative care). Palliative radiation therapy is given to relieve symptoms, restore function, relieve suffering caused by cancer and improve quality of life2. More specifically, radiation can help relieve pain, control bleeding or ulceration, prevent adjacent organ compression or obstruction from a tumour, and shrink tumours that are causing symptoms2.

What does the data say about palliative treatment for advanced prostate cancer?

In 2009, approximately 30% of metastatic prostate cancer patients were treated with chemotherapy one-year prior to death (Figure 1)

  • Palliative chemotherapy is given to cancer patients to decrease tumour burden, relieve symptoms and improve survival.
  • For prostate cancer, docetaxel is recommended as a treatment option for men with castrate-resistant prostate cancer.4
  • In 2002, Tannock et al.1 conducted a clinical trial with over 1,000 metastatic castrate-resistant prostate cancer patients with the primary goal being to measure survival after the administration of two chemotherapy treatment regimens – docetaxel and mitoxantrone. The overall results demonstrated that treatment with docetaxel led to superior survival and improved rates of response in terms of pain, serum PSA level, and quality of life.
  • Figure 1 illustrates that approximately 20% of prostate cancer patients who died in 2009 received docetaxel within one year prior to death.
  • Similarly, a higher proportion (more than 30%) of prostate cancer patients who died in 2009 received docetaxel at some time prior to their death, suggesting that many hormone-refractory prostate cancer patients in the palliative phase survive for more than one year.
  • Many factors go into the decision to use chemotherapy, including performance status, organ function, and patient preference.
  • There are currently no benchmarks are targets related to the level of access that patients should have to chemotherapy in the final stages of their life. As such, it is difficult to definitively say whether this proportion is either good or bad.

Patients with prostate cancer treated with chemotherapy may visit the emergency room or be admitted to hospital within 4-weeks of treatment (Figure 2)

  • In 2011, 28% of the patients with prostate cancer treated with docetaxel visited the emergency department within 4 weeks of receiving treatment.
  • Of those patients receiving docetaxel, 20% were admitted to hospital via the emergency department and 9% were directly admitted to the hospital within four weeks of treatment.
  • Reasons for visits to the emergency department varied. Neutropenia, fever and infection were identified as the top reasons for both inpatient and emergency department admits. Other reasons included pain and pain management (data not shown).
  • These rates are much less than what is seen for breast and colon cancer link to Unplanned Hospital visit write-up2.7.

Palliative radiation is used for symptom and pain management among end-of-life prostate cancer patients at the end-of-life (Figure 3)

  • Several studies have demonstrated that the use of palliative radiation is an effective, safe and readily available treatment, for local symptoms of hormone-refractory prostate cancer5.
  • Overall, patients with multiple symptoms are more likely to experience treatment failures and poor treatment outcomes6.
  • The use of radiation for palliative treatment has not increased significantly during the years reported. In 2008 and 2009, a little over 30% of prostate cancer patients received palliative radiation within one year prior to their death.
  • There is, however, variation among LHINs from 22% to 55% of patients receiving palliative radiation. More than 50% of patients were given palliative radiation in North West LHIN in 2009.
  • A study on the optimal use of palliative radiotherapy in New South Wales, Australia conducted by Jacob et al. found that palliative radiotherapy was indicated in 23% of all patients newly diagnosed with prostate cancer in 2009. The vast majority (96%) of palliative radiotherapy indications in newly diagnosed prostate cancer were for the treatment of bone metastasis. Further, up-front palliative radiotherapy was indicated for the treatment of local symptoms arising from prostate cancer in 4% of patients included in the study.8

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