Abstract
Dear Editor:
In today's oncology practice, the term palliative chemotherapy is used to describe the systemic management of incurable malignancies such as stage IV solid tumors. 1 However, the clinical relevance of this term when first coined may not be the same in today's era of oncology. Today chemotherapy for stage IV can be given for the purpose of palliation, to affect a response, or to improve survival.2,3 Hence, “palliative chemotherapy” does not adequately describe the improved survival attained in the last few decades via systemic therapy in stage IV tumors such as non–small cell lung (NSCLC), colorectal, and breast. For example, in a meta-analysis of chemotherapy versus best supportive care in patients with advanced NSCLC, there was an absolute improvement in survival of 9% at 12 months, increasing overall survival from 20% to 29%. 4
Moreover, the term palliative chemotherapy does not account for the hormonally, biologically, and immunologically mediated systemic therapies that have also been shown to improve survival but are not traditional cytotoxic chemotherapy. An example of this is seen in erlotinib, a small molecule inhibitor against epidermal growth factor receptor (EGFR) receptors, that prolongs the survival in patients with NSCLC after first-line or second-line chemotherapy has failed, resulting in overall survival of 6.7 months versus 4.7 months in the placebo arm. 5
Sole palliative function is seen when radiation is provided for pain relief, preservation of function, and maintenance of skeletal integrity in bone metastases. Similarly, hospice care offers palliative or comfort care using methods of pain and symptom control when treatment for curing or controlling the cancer is no longer helping the patient. The hospice literature does not recognize that systemic therapy for incurable cancer can improve survival even without cure.
This concept of labeling therapy based on its purpose is not new. The National Comprehensive Cancer Network employs this practice in its guidelines for the use of myeloid growth factors along with cancer treatment where treatment intent has been divided in to three categories: 1) curative adjuvant, 2) prolonging survival and quality of life therapy and 3) symptom management and quality of life. 6 We concur with these distinctions that separate a purely palliative approach from a therapy whose intent is both to prolong survival as well as to improve quality of life.
In summary, palliative chemotherapy for stage IV incurable adult solid tumors inadequately labels a treatment that has been proven to lead to more than just relief of symptoms and pain and now includes agents other than cytotoxic drugs. The treatment of cancer has dramatically changed in the strategies for improving overall survival of incurable stage IV patients, hence historic nomenclature should be modernized to keep up. We propose that the term “life-prolonging systemic therapy” be used to describe systemic therapies for incurable adult solid tumors rather than palliative chemotherapy.