Palliative Care Was not Considered
The authors presented a review article of “conventional and innovative diagnostic methods [. . .] and highly refined therapeutic strategies to patients with CUP” (1). They describe the highly palliative situation of patients with mean survival times of 8–11 months and 2-year survival periods of only 20%. The recommendation is to give these patients platinum-based chemotherapies, which—while prolonging their remaining lives to such a minimal extent that the purpose of using such therapies is questionable—have substantial adverse effects and lead to impaired quality of life.
On the other hand, they do not make any mention whatsoever of patients’ early referral to palliative care services, which support the quality of life and remaining lifespan in exactly this group of patients—and has been internationally recommended for years. In the article, the word “palliative” is mentioned only in association with radiotherapy. Symptom control, quality of life, or even the wishes of patients with a terminal illness do not count. What was not discussed is the fact that chemotherapy does not benefit patients in the last six months of their lives, irrespective of the extent to which their tumor disease had already impaired them (2).
In view of the heterogeneous CUP group, it is incomprehensible that expensive new antibodies are considered a “modern therapeutic concept.” Even in well-known indications, only 2.9% (!) of recently licensed modern cancer treatments whose long-term use has been investigated in a study contributed in any way to extending patients’ lives and improving their quality of life (3).
Recommending expensive modern therapeutics outside clinical studies, without confirmed benefit and with harm, without providing information on comprehensive palliative care as an alternative contravenes each and every one of the four medical ethical principles.
The vast majority of the patients in a palliative situation wants therapy that targets the symptoms and supports quality of life. For this reason, the review article is probably useful only for the cancer industry and a minority of patients—and the latter mostly has unrealistic expectations of what therapy can deliver (4).
Dr. med. Matthias Thöns
|1.||Zaun G, Schuler M, Herrmann K, Tannapfel A: CUP syndrome—metastatic malignancy with unknown primary tumor. Dtsch Arztebl Int 2018; 115: 157–62 VOLLTEXT|
|2.||Priggerson, Bao Y, Shah MA, et al.: Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol 2015; 6: 778–84 CrossRef MEDLINE PubMed Central|
|3.||Davis C, Naci H, Gurpinar E, Poplavska E, Pinto A, Aggarwal A: Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009–13. BMJ 2017; 359: j4530 CrossRef MEDLINE PubMed Central|
|4.||Mehlis K, Winkler EC: Ethische Analyse lebensverlängernder Behandlungen. Der Onkologe 2016; 22: 844–51 CrossRef|