Deprescription during last year of life in patients with pancreatic cancer: Optimization or nihilism?

I read with great interest the article by Morin et al regarding the lack of deprescription of commonly used preventive drugs during the last year of life in patients with cancer.1 In an era of increasing costs and personalized medicine in treating cancers, the authors’ findings support the case for the excessive use of many commonly prescribed drugs during the last part of life of the majority of patients with cancer, presenting an important example of the need for the optimization of resources in this scenario. However, I do believe that these results should be read and discussed while keeping in mind the extremely different clinical behavior, prognosis, and treatment recommendations of each individual tumor type. In the article by Morin et al, in which data from 2007 to 2013 were used, pancreatic cancer is reported to be the fifth most common cause of cancer-related death.1 Currently, pancreatic cancer is projected to become the second most common cause of cancer-related death in Western countries,2 with a mean survival of <1 year and 5-year survival rates of approximately 5%. In this scenario, it is quite obvious that the majority of treatments for pancreatic cancer, either active or palliative, are prescribed during the last year of life, a timeframe considered in the article by Morin et al1 to be the one during which deprescribing preventive drugs should be strongly considered. In the article by Morin et al, the most common preventive drugs to be discontinued included those used to treat hypertension and diabetes, antithrombotic agents, and statins.1 However, the majority of patients with pancreatic cancer experience diabetes as a result of the disease, which worsens their quality of life and possibly life expectancy, and therefore it is not surprising that it was found to be the cancer type with the highest rate of use of antidiabetic drugs (28%), even during the last month of life. In addition, pancreatic cancer is considered to possibly be the most prothrombotic tumor type, and thus preventive antithrombotic treatment often is considered important.3 I agree that the deprescription of cardiac drugs such as antihypertensive agents should be strongly considered in all terminally ill patients with cancer because they might not only be useless but even detrimental. However, because cardiotoxicity is among the adverse events associated with many chemotherapy regimens for pancreatic cancer,4 it is likely that primary care physicians and oncologists are reluctant to do so because this might adversely affect the chances for these patients to receive the most effective treatments. Finally, the use of both metformin and statins recently has been consistently associated with improved survival in patients with pancreatic cancer,5 although it is not clear whether this is due to a direct antitumor mechanism, which is supported by findings regarding statin use in the preventive setting,6 or by reducing the risk of complications. In Supporting Table 8 of the article by Morin et al,1 the costs of drugs for pancreatic cancer are highlighted, and an increase of 104% in the last year of life is evident, and is the highest after that for brain cancer. This is not surprising because, unfortunately, this is the period of time from diagnosis to death when symptoms start and cure is initiated in the majority of patients with pancreatic cancer. Preventive agents likely account for a small percentage of the costs during the short lifespan of a patient with pancreatic cancer. The case for deprescribing or even not initiating treatments during the last and only year of life of the majority of patients with such a lethal cancer might appear nihilist and not an optimization. Considering all these arguments, I believe that it is somehow simplistic to discuss deprescribing common preventive drugs while pooling together very common diseases with an extremely long survival expectancy such as prostate or breast cancer, for which the last year of life usually comes at the end of a long course of treatment, with rarer and more lethal cancers with a fatal prognosis, such as pancreatic cancer. In the era of personalized medicine, we should instead keep in mind that there is a person beyond each number. Optimization of care is a means and not a goal to cure persons, especially those with a very short life expectancy. These efforts should include patient-reported outcomes and the measurement of the value of care and not solely medical or economic considerations. No specific funding was disclosed. The author made no disclosures.

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