Chemotherapy: how much does it actually improve survival?
Chemotherapy drugs have had little effect on cancer survival in adults according to an analysis just published in BMJ (British Journal of Medicine).The author notes that although there have been advances in chemotherapy in recent years, a thorough examination of the data reveals that...
"Despite considerable investment and innovation, chemotherapy drugs have had little effect on survival in adults with metastatic cancer."
In fact, the data on the survival benefits of chemotherapy are so disturbing that they raise questions about ethics, drug trials and approval, and patient consent.
"The approval of drugs with such small survival benefits raises ethical questions, including whether recipients are aware of the drugs’ limited benefits, whether the high cost:benefit ratios are justified, and whether trials are providing the right information."
Key messages include:
"Advances in chemotherapy have contributed little to population cancer survival
Responses in clinical trials may not apply to patients treated in the community
Evaluation outside trial centres is essential to ensure that scarce resources are not squandered
Stricter approval criteria are needed to achieve ethical treatment and reduce cancer costs
Ethical informed consent and empowerment of patients must be promoted"
"Many irregularities and competing interests—in pharma, in trials, in government approval, and in the clinical use of cancer drugs—impact ethically on the care and costs of patients with cancer. Non-representative clinical trials with imprecise endpoints and misinformed patients with unrealistic expectations compel interventions that are mostly not in their best interests. Spending a six figure sum to prolong life by a few weeks or months is already unaffordable, and inappropriate for many of the 20% of the (Western) population who will almost inevitably die from solid tumour metastases."
"Ethical cancer care demands empowerment of patients with accurate, impartial information followed by genuinely informed consent in both the clinical trial and therapeutic settings. Intensified prevention, earlier detection, more prompt and radical treatment of localised and regional disease, together with highly skilled, earlier, supportive care are the important yet underfinanced priorities in cancer control. Ethical impediments to sound practice need to be addressed and corrected. Above all, the efficacy bar for approval needs to be raised for both new and existing cancer drugs—by using more meaningful statistical and disease specific criteria of risk-benefit and cost-benefit. Finally, aggressively targeting the less than ethical actions of stakeholders in the heavily veiled medical-industrial complex may be the only way forward: current market driven rather than health driven priorities and practices do not benefit cancer patients."
The entire paper can be downloaded here, and an illuminating, brief interview with the author can heard by clicking on the arrow in the upper left corner of the image below:
[embed]https://soundcloud.com/bmjpodcasts/cancer-drugs-survival-and-ethics[/embed] 
The editor-in-chief of BMJ in an accompanying editorial states:
"People with cancer are living longer now than 40 years ago. This is clearly good news. But how much of this improvement can we attribute to drug treatment? Not much, concludes Peter Wise this week in an article I humbly suggest all oncologists should read. The nearly 20% improvement in five year survival over the past four decades is probably mainly due to improved early diagnosis and treatment rather than developments in cytotoxic chemotherapy, he says. And patients are being badly misled by over-enthusiastic accounts of what chemotherapy can achieve. Many expect a cure. In reality they will gain on average only a few months of extra life."
Moreover...
"Unjustified enthusiasm for cancer drug treatments comes at huge cost, financial and personal (including treatment related deaths and reduced quality of life), and increased risk of dying in hospital rather than at home. Many patients don’t realise that opting for supportive rather than active treatment—often called “refusal”—is an option and may give them longer as well as better quality life than chemotherapy. Conflicts of interest among clinicians compound their reluctance to have tricky conversations."
The editor summarizes the author's recommendations in light of this data:
"Wise concludes with a call for higher bars for drug approval for new and existing drugs. Ethical cancer care demands empowerment of patients, he says, with accurate, impartial information followed by genuinely informed consent. And funds and attention should shift to prevention, early detection, prompt and radical treatment of localised and regional disease, and early provision of supportive care. Only then will cancer care serve patients rather than governments and industry."