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The use of chemotherapy for curing cancer at the end of life is a debated and complex issue. A case study of a man with lung cancer is discussed to try and determine when chemotherapy is no longer beneficial and it is enough and should be stopped.

Patients with metastatic breast cancer may benefit from autologous bone marrow transplantation (ABMT), but this treatment may be too expensive for widespread use. Patients who receive ABMT are infused with their own bone marrow to strengthen their immune system after chemotherapy. A mathematical model was used to estimate the survival time and cost of treatment for a hypothetical group of 45-year-old women with metastatic breast cancer who were treated with high dose chemotherapy followed by ABMT, or with standard chemotherapy. One year after starting treatment, 36.1% of the patients who received intensive chemotherapy followed by ABMT were in complete remission, compared to 8.2% of the patients treated with standard chemotherapy. Five years after treatment, average survival time for patients who received intensive chemotherapy followed by ABMT was 27.4 months, and average survival time for patients who received standard chemotherapy was 21.4 months. The cost of ABMT was $115,800 per year of life saved.

Physicians should begin to tell cancer patients the truth about their prognosis and the possible benefits of specific treatments. A 1998 study found that 82% of the cancer patients surveyed overestimated their prognosis and were 2.6 times more likely to choose aggressive treatment rather than palliative care. However, their average survival rates were no better than the rates in those who chose palliative care. Many physicians cannot admit that they have failed to cure the patient. Being honest with the patient is consistent with the principles of informed consent and patient autonomy.

Patients needing complex surgery should be referred to hospitals that perform many such procedures. A 1998 study found that hospitals that did many cancer surgeries had lower mortality rates. Patients with heart disease have been shown to benefit from treatment at hospitals that treat many such patients. These so-called high volume hospitals could substantially lower mortality rates in many patients.

Thomas J. Smith responds to a letter to the editor about his article "The Role of Chemotherapy at the End of Life: When is Enough Enough?" in a previous issue.

Importance: Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations., Objective: To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers., Design, Setting, and Participants: From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients., Intervention: Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation., Main Outcomes and Measures: The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed., Results: In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99)., Conclusions and Relevance: To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers., Trial Registration: ClinicalTrials.gov Identifier: NCT03611309.

A major challenge in value-based health care is the lack of standardized health outcomes measurements, hindering optimal monitoring and comparison of the quality of health care across different settings globally. The International Consortium for Health Outcomes Measurement (ICHOM) assembled a multidisciplinary international working group, comprised of 26 health care providers and patient advocates, to develop a standard set of value-based patient-centered outcomes for breast cancer (BC). The working group convened via 8 teleconferences and completed a follow-up survey after each meeting. A modified 2-round Delphi method was used to achieve consensus on the outcomes and case-mix variables to be included. Patient focus group meetings (8 early or metastatic BC patients) and online anonymized surveys of 1225 multinational BC patients and survivors were also conducted to obtain patients' input. The standard set encompasses survival and cancer control, and disutility of care (eg, acute treatment complications) outcomes, to be collected through administrative data and/or clinical records. A combination of multiple patient-reported outcomes measurement (PROM) tools is recommended to capture long-term degree of health outcomes. Selected case-mix factors were recommended to be collected at baseline. The ICHOM will endeavor to achieve wide buy-in of this set and facilitate its implementation in routine clinical practice in various settings and institutions worldwide.