title: Withdrawal of anticancer therapy in advanced disease: a systematic literature review.
abstract: BACKGROUND
  Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Conventional cytotoxic agents are administered intravenously and have major life-threatening toxicities. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. MTAs are substantially more expensive, between £2-8 K per month, and perceived as easier to start than stop.
  
  
  METHODS
  A systematic review of decision-making concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on MTAs. Nine electronic databases searched. PRISMA guidelines followed.
  
  
  RESULTS
  Forty-two studies included. How are decisions made? Decision-making was shared and ongoing, including stopping, starting and trying different treatments. Oncologists often experienced 'professional role dissonance' between their self-perception as 'treaters', and talking about end of life care. Why are decisions made? Clinical factors: disease progression, worsening functional status, treatment side-effects. Non-clinical factors: physicians' personal experience, values, emotions. Some patients continued treatment to maintain 'hope', often reflecting limited understanding of palliative goals. When are decisions made? Limited evidence reveals patients' decisions based upon quality of life benefits. Clinicians found timing withdrawal particularly challenging. Who makes the decisions? Decisions were based within physician-patient interaction.
  
  
  CONCLUSIONS
  Oncologists report that decisions around stopping chemotherapy treatment are challenging, with limited evidence-based guidance outside of clinical trial protocols. The increasing availability of oral MTAs is transforming the management of incurable cancer; blurring boundaries between active treatment and palliative care. No studies specifically addressing decision-making around stopping MTAs in clinical practice were identified. There is a need to develop an evidence base to support physicians and patients with decision-making around the withdrawal of these high cost treatments.
authors.affiliation: Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom. gcc29@medschl.cam.ac.uk.
authors.forename: G
authors.initials: G
authors.lastname: Clarke
authors.affiliation: Carroll Lab Cambridge Research Institute, Cancer Research UK Cambridge Research Institute, Cambridge, United Kingdom. simon.johnston@cruk.cam.ac.uk.
authors.forename: S
authors.initials: S
authors.lastname: Johnston
authors.affiliation: Department of Oncology, University of Cambridge, Cambridge, United Kingdom. pippa.corrie@addenbrookes.nhs.uk.
authors.forename: P
authors.initials: P
authors.lastname: Corrie
authors.affiliation: Medical Library, University of Cambridge, Cambridge, United Kingdom. ilk21@cam.ac.uk.
authors.forename: I
authors.initials: I
authors.lastname: Kuhn
authors.affiliation: Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom. sigb2@medschl.cam.ac.uk.
authors.forename: S
authors.initials: S
authors.lastname: Barclay
mesh_terms: D000970:Antineoplastic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D000066491:Clinical Decision-Making; D006801:Humans; D009369:Neoplasms / Q000188:drug therapy* / Q000473:pathology*; D013727:Terminal Care; D013997:Time Factors; D028761:Withholding Treatment
chemical_list: D000970:Antineoplastic Agents