Addressing Overtreatment in End-of-Life Cancer Care

Prof David Kerr explores a recent review on improving end-of-life care for cancer patients, addressing overtreatment and the shift toward palliative approaches.
https://www.medscape.com/viewarticle/addressing-overtreatment-end-life-cancer-care-2025a10003d0?src=soc_yt

--TRANSCRIPT--
Hello. I'm David Kerr, professor of cancer medicine at the University of Oxford. I would like to talk about a nice review that Nathan Cherny, a pal of mine, wrote. We've been friends and colleagues for almost 30 years through the European Society for Medical Oncology (ESMO) and other areas. He and a very talented group colleagues have written a paper with an important title: “A Taxonomy of the Factors Contributing to the Overtreatment of Cancer Patients at the End of Life. What Is the Problem? Why Does It Happen? How Can It Be Addressed?”

The structure for the review is beautifully laid out at the beginning. What do we mean by overtreatment? This means that many patients who are approaching the end of life receive treatments, like directed anticancer therapies, that are unlikely to provide clinically meaningful benefits and may do more harm than good.

This is an expression that I use often in the clinic when I'm explaining to patients that we have reached the end of the road in active interventions, such as chemotherapeutic drugs, that will do more harm than good. It doesn't stop us from doing our very best to look after patients. We focus on improving the quality of life and maintaining that for as long as we can, while continuing to care and look after the patients.

It's not a fracture or a parting of the ways, but accepting that this particular element of cancer care, the active cancer-directed treatment, is over. Therefore, we have a palliative symptomatic approach, looking at it that way.

Clearly the disbenefits are side effects, harm rather than good, cost to the healthcare system, and delays in the appropriate discussions about end-of-life care. Patients may say, “No, no, please don't refer me to the palliative care nurse or to the hospice” because that carries with it the sense that their life is enormously foreshortened. I'm sure that those of you who are clinicians would recognize that sense of horror that patients can express at that time.

Overtreatment may even, one would argue, accelerate death when you consider those 1% or 2% mortality rates that can be associated with some treatments that we offer.

Having defined the problem, next is understanding why it happens. This is a complex area. We know that there are social, psychological, and cognitive factors, and it affects the whole microcosm of the oncologist, the patients, and their families, all of whom are wrapped together in this extraordinary journey that we're privileged to be a part of — looking after cancer patients.

There are heuristic biases within us as oncologists related to treatment trends, new drugs coming through, having a strong emotional connection with patients we may have looked after for years. With this in mind, we want to do the very best that we can, while understanding that chemotherapy is not a psychological crutch but it sometimes may appear to be so for certain patients and their families who say “there must be something.” Even if there's a 0.1% chance that it would help, surely we would offer it.

There is a set of intrinsic biases in us that we may not recognize. Similarly with patients — the latest breakthrough that they get on TikTok or YouTube and the sense that, in our extraordinarily integrated world via the internet, people pick up bits and pieces all the time and are looking for medical cures, wherever they might come from. A whole host of factors contributes to this from both sides of the consultation desk, both our side and the patient/family side.

For a moment, I don’t sit opposite patients; I sit beside them. What can we do about it? Better training in communication: being able to communicate gently and positively — but with clarity — that end-of-life discussion, the introduction of palliative care early, and seeing what we can do to make a real difference and improvement in how we can have these difficult conversations in a way to make them positive.

Transcript in its entirety can be found by clicking here:
https://www.medscape.com/viewarticle/addressing-overtreatment-end-life-cancer-care-2025a10003d0?src=soc_yt