Introduction

Palliative care for patients with advanced cancer involves a focus on alleviating suffering and promoting quality of life. Understandably, the emphasis of palliative care is on mitigating the impact of the malignancy on the individual rather than persisting in the direct battle against the cancer. In this shift toward palliation, patients and providers sometimes lose sight of the potential value that anticancer therapy can provide in terms of relieving symptoms and preserving function. Clearly, systemic anticancer therapy such as chemotherapy, hormonal therapy, or other modalities (monoclonal antibody infusion, gene therapy, etc.) may introduce significant risks to the patient with advanced cancer. There are not only the risks related to toxicity, but also the risk of added expense and the loss of valuable time and energy, which are precious and could be used in other ways. The uncertainty regarding outcomes and the complexity involved in making treatment decisions have made the issue of palliative systemic therapy controversial and sometimes a source of conflict between providers and/or family members.

This chapter outlines the therapeutic rationale for considering palliative systemic therapy, including how to select patients who are most likely to benefit from therapy, how to ascertain patient preferences, and how to choose the appropriate time to initiate therapy as well as discontinue it. Basic information related to chemotherapy, hormonal therapy, and monoclonal antibody therapy is also reviewed.

Determining whether palliation is the appropriate goal

The first step in selecting patients for palliative systemic therapy is to ensure that the patient is not being prematurely offered palliative therapy when a realistic chance of cure is still available.