Onkologische Systemtherapie bei Palliativpatienten: Beendigung oder Fortführung?

Zusammenfassung

Fortschritte in der onkologischen Therapie von nicht heilbaren Tumorpatienten machen die Einschätzung einer korrekten Prognose schwieriger. Mittels molekularer Marker unterteilen sich die diversen Tumorerkrankungen in immer kleinere Subgruppen mit unterschiedlichen Prognosen. Eine Vorstellung im interdisziplinären Tumorboard sollte Standard sein. Um übersteigerte und unrealistische Erwartungen am Lebensende zu minimieren, bedarf es optimaler Aufklärung und der Integration einer frühen palliativen Betreuung in den weiteren Behandlungsverlauf.

Abstract

One third of oncological treatment costs per patient is allocated to the last phase of life. In the era of molecular oncology and immuno-oncology, patients benefit from new treatment options inducing durable and long-lasting responses. However, it becomes more difficult to estimate the prognosis of oncology patients. The treatment indication is based on the evidence from randomized controlled studies. In contrast, the decision, when to stop treatment at the end of life and provide best supportive care, is an emerging and challenging situation in routine clinical care of oncologists and palliative care teams. Up to 50% of oncology patients receive chemotherapy within the last 4 weeks before death, thus it becomes evident to stop futile treatment. Reliable biomarkers to predict the response of immunotherapy are lacking for most of solid tumors. Several palliative prognostic scores have been validated to calculate the probability of survival in the next 30 – 60 days. Unfortunately, there is no consensus on which score should be preferred and none was validated in period of immuno-oncology. The estimation of expectation of life by an interdisciplinary medical team is recommended by the German guideline of palliative medicine. Of note, treating physicians often overestimate the prognosis of patients, and shared decision making whether to start, to continue or to stop therapy for the individual patient remains difficult. Early integration of palliative medicine and advance care planning focus on the patientʼs medical perspective. Clinical trials investigating the integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Changes at the system level are necessary for implementation of advance care planning to improve the quality of the end of life of oncology patients.

Kernaussagen

• In den letzten Lebenswochen sollte wünschenswertweise keine onkologische Systemtherapie durchgeführt werden.

• Mittels molekularer Marker unterteilen sich die diversen Tumorerkrankungen in immer kleinere Subgruppen mit unterschiedlichen Prognosen und Therapie-Ansprechwahrscheinlichkeiten.

• In Zeiten der Immunonkologie ist es deutlich schwieriger geworden, die Prognose palliativ-onkologischer Patienten einzuschätzen, da es keine Biomarker gibt, die zuverlässig ein Ansprechen einer solchen Therapie vorhersagen können.

• Im Unterschied zur Chemotherapie profitiert ein kleiner Teil der Patienten von einer Immuntherapie auch in der fortgeschrittenen Krankheitssituation dauerhaft, teilweise über Jahre.

• Immuntherapie wird auch bei schlechterem Allgemeinzustand oft besser vertragen als vergleichbare Chemotherapie.

• Palliative Prognose-Scores sind nicht auf die Immuntherapie ausgerichtet.

• Es bedarf der frühzeitigen Integration von Palliativmedizin und Advance Care Planning, um die angebotene Therapie mit den Lebenszielen unserer Patienten zu harmonisieren und den Prozess der Entscheidungsfindung im weiteren Verlauf zu begleiten.

• Die Entscheidung, bis zu welchem Zeitpunkt eine onkologische Therapie begonnen oder abgebrochen wird, kann nur individuell mit dem Patienten und dessen Angehörige getroffen werden. Hilfreich ist hier die Einschätzung des Behandlerteams und die Vorstellung in Tumorboards.

Schlüsselwörter

Palliativpatienten - Onkologie - nicht heilbare Tumorerkrankung - Aufklärung - Überlebenswahrscheinlichkeit - Immuntherapie - Chemotherapie

Key words

palliative patients - oncology - immunooncology - prognosis - immunotherapy - end of treatment

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