Use of Chemotherapy and Immunotherapy the Last Four Weeks of life in Patients with Lymphoma in An Anticancer Center with Focus On the Impact of Time Period (1998-2002 and 2003-2008).

Despite improvements in the outcome of malignant lymphoma, a great number of patients will ultimately died from their affection. The adequate timing for cessation of chemotherapy or immunotherapy is difficult to establish in these patients with chemosensitive tumours. Some palliative care performance index claimed that less than 10% of patients should receive chemotherapy the last 2 weeks of life.

In order to collect epidemiologic data about “agressive therapy” in the endlife and in order to understand the decision making process, we performed a large scale study in an anticancer center and we reported here the preliminary data related to malignant lymphoma.

From 1998 to 2008, 464 adult patients (pts) treated in one single institution by at least one chemotherapy regimen for malignant lymphoma died from the evolution of their disease, therapy-related complications or secondary neoplasia. Median age at death was 66 years, there were 286 male (62%), 407 B cell lymphoma (88%), 26 pts with T cell lymphoma (5%) and 31pts with Hodgkin disease (7%). Median time between diagnosis and death was 24 months. Forty four % of pts died inside the institution. The percentage of deaths due to primary failures in first line (progression or toxic deaths) was significantly decreased between 1998-2002 (30%) and 2003-2008 (20%) Clinical and pathologic characteristics were comparable between the two time periods. and the rate of patients treated in third line or more was not significantly different between the periods (49% vs 56%). Among the whole 464 pts, 172 (37%) received a chemotherapy or immunotherapy regimen the last 4 weeks of life and 107 (23%) the last two weeks. Median time between last regimen and death was 8 weeks. No evident predictive clinical factors has been found to understand the making decision process. The administration rates of chemotherapy the 4 weeks before death was 41% for the 1998-2002 time period versus 34% for the 2003-2008 period (p= 0.1). Among the 172 pts receiving chemotherapy or immunotherapy the last 4 weeks, 58 pts (34%) were in first line of therapy and died from evolution or toxicity, 30 pts were in second line (17%), 27 pts were in third line (16%) and 58 pts in more than 3 lines (33%).Finally, we can estimate that 18% of the 464 patients who died had received a probably useless therapy the last 4 weeks. This rate is comparable between the 2 times periods: 17% versus 19%. Nine pts on 74 pts (12%) with B cell lymphoma received Rituximab the 4 last weeks in the first period since 29 pts on 73 B cell lymphoma (40%) received it in the second period. including 14 pts/73 in third line or more.

These preliminary data suggest an improvement of health care in the initial management of malignant lymphoma with less toxic death or progressive disease maybe related to best supportive care and to a generalized use of Rituximab in B cell lymphoma. Furthermore, only 18% of patients who died received the last four weeks a therapy which can be retrospectively regarded as irrelevant because it was administered without benefit in third line or more. Ethical and economical considerations will be addressed. Further data are needed in order to help physicians, patients and relatives to determine the optimal timing for cessation of “active therapy” and to consider the best palliative care setting.

No relevant conflicts of interest to declare.