Treating metastatic lung cancer at the end of life: Treatment incidence, treatment goals and views in hindsight

Chapter 1 provides an introduction to the topic of this thesis: treating metastatic lung cancer at the end of life. Lung cancer is currently one of the most frequently diagnosed cancers worldwide. Systemic treatments such as chemotherapy, immunotherapy and targeted therapy with Tyrosine Kinase Inhibitors (TKIs) aim to relieve symptoms with temporary disease control. However, it may also cause side effects which may lead to a decreased quality of life. A trend towards increasing use of systemic treatments for metastatic lung cancer has been shown, often called “aggressive care”. Several studies have shown that treatment at the end of life may result in potential burdensome and inappropriate hospital admissions and consequently hospital deaths. For patients with metastatic lung cancer, treatment could be aimed at life extension or quality of life without any prospect of cure. However, many patients receiving chemotherapy for incurable cancers may not understand that the treatment is unlikely to be curative, which could compromise their ability to make treatment decisions in line with their treatment goals. • The percentage of metastatic lung cancer patients who received chemotherapy or TKIs in the last month of life in the Netherlands. • The percentage of metastatic lung cancer patients who died inside the hospital and whether hospital death is associated with receiving systemic treatment in the last month of life. • The type and the feasibility of treatment goals that patients and their oncologists have when starting systemic treatment. • To what extent the patients’ and their oncologists’ treatment goals are achieved after systemic treatment and whether this differed between types of therapy. In addition, whether it was their right decision to start treatment in hindsight. • The perspective of the relatives in hindsight on the achievement of the patients’ treatment goals and whether they are satisfied about the patients’ treatment choice. Chapter 2 presents the percentage of metastatic lung cancer patients who receive chemotherapy or TKIs in the last month of life in the Netherlands. Chapter 3 reports on the percentage of metastatic lung cancer patients who died inside the hospital in the Netherlands and whether hospital death is associated with receiving systemic treatment in the last month of life. Chapter 4 focusses on the treatment goals patients and oncologists have when starting a systemic treatment, what the concordance of patients and oncologist is between these goals and how feasible they think these goals are. Chapter 5 describes to what extent patients’ and oncologists’ treatment goals were achieved after systemic treatment and whether it was the right decision to start treatment in hindsight. Chapter 6 elaborates on the perspective of relatives in hindsight on the achievement of patients’ treatment goals and whether they are satisfied about the patients’ treatment choice. Chapter 7, the General Discussion, starts off with methodological considerations of the research presented in this thesis. Next, the general discussion provides a description of the main findings from each chapter in relation to previous research and reflect on treatment, place of death and preferred and achieved treatment goals of metastatic lung cancer patients. Also views of oncologists and relatives on treatment goals and treatment decision are discussed. In the closing part of the chapter, some recommendations for clinical practice and future research are described. These include the need for palliative care at the end-of-life, recent research on the percentage of treated metastatic lung cancer patients and further research on the reason and satisfaction on choosing not to treat metastatic lung cancer according to patients and oncologists.