Salvage Chemotherapy
Salvage chemotherapy is a somewhat morbid term and little used by medical professionals interacting with patients. The phrase is used in medical journals written in cold dispassionate language where it refers to chemotherapy given to a patient when other options are exhausted. The attempt is to “salvage” the person’s life with last ditch measures. Salvage therapy is a broader term that can include surgery and any procedure used in a similar manner.
A somewhat related term is refractory cancer for cancer that does not respond to treatments. Many of the references to salvage chemotherapy in the medical literature are for what the authors call refractory or resistant cancer. This makes sense, of course, because if the cancer responded well to the initial chemotherapy or surgery, no salvage chemotherapy would be needed.
There is no special chemotherapy drug or combination of drugs that are used in salvage chemotherapy. A regimen that might be a first-line treatment in one situation for one patient may be considered salvage chemotherapy treatment in another situation. This may change in the future as targeted therapies become more widely used. It is possible that oncologists of the future will use targeted therapy as first-line treatment and old-style cytotoxic drugs only as salvage chemotherapy for patients that have not gotten better.
Patients who have not shown positive response to primary treatment regimens are often directed to clinical trials for new medicines and treatments. “Clinical trial” sounds more optimistic and upbeat than salvage therapy, even if it often operates as a form of salvage therapy. Salvage therapy is also a place where doctors can try new regimens even outside the formal clinical trial process. Experienced and informed oncologists may choose to tweak established regimens in the salvage period.
Palliative Chemotherapy
The phrase palliative chemotherapy conveys some despair as it refers to chemotherapy given without the intent to cure. Palliative means given to reduce pain or discomfort, and although not all palliative medicine is given when there is no hope and doctors expect death, and in the case of palliative chemotherapy that is often the case. Palliative chemotherapy is administered to reduce tumor size or prevent further growth even though the doctor does not expect the cancer to go into remission. It is thus different from adjuvant chemotherapy that might be given after surgery as part of a comprehensive plan to attack the cancer.
Given the widely known side effects of chemotherapy and the fact that it often degrades the quality of life for patients, many wonder if palliative chemotherapy is a contradiction in terms.
Doctors are usually more lenient in listening to the wishes of the patient when it comes to palliative chemotherapy. While the doctor may insist on a particular primary regimen for treatment, when it comes to palliation the wishes of the patient and family are considered more. There are downsides to chemotherapy used even in palliation, and these may outweigh the benefits to the patient’s comfort. An article in the Journal of the American Medical Association Oncology cast skepticism on the practice of palliative chemotherapy, which the author said was often given when the patient was feeling little or no discomfort and which made the patient feel worse.
National Public Radio reports more than half of patients with terminal cancer get palliative chemotherapy and that there is skepticism as to whether the therapy is worth it. Getting palliative chemotherapy increases the odds the patient will die in an intensive care unit and decreases the odds the will die at home or where he/she wishes to die. The American Society of Clinical Oncology and the American Board of Internal Medicine (ABIM) Foundation issued recommendations in 2012 saying, “For patients with advanced solid-tumor cancers who are unlikely to benefit, do not provide unnecessary anticancer therapy, such as chemotherapy, but instead focus on symptom relief and palliative care.” https://connection.asco.org/magazine/features/choosing-wisely-constructing-top-five-list-oncology
An article published in the journal BMC Palliative Care claimed that chemotherapy can be a “powerful palliative intervention” and that palliative care doctors and oncologists don’t understand each other. Palliative chemotherapy can increase quality of life for cancer patients, the authors say. One problem, the authors said, is that oncologists don’t have a reliable method of predicting which patients will benefit from palliative chemotherapy. They call for more research into what types and regimens of palliative chemotherapy actually reduce symptoms – an evidence-based approach.