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To the Editor. With interest we read the paper by Boddaert et al.  about quality of end-of-life cancer care in The Netherlands and recommend the authors with their work. Quality of end-of-life care is of great importance to both patient and relatives. Inappropriate interventions during the disease, certainly in the last 30 days of life, are undesirable. We agree to the benefit of a multifactorial approach in palliative care.
Nevertheless, we have concerns about the use of the term “inappropriate care”, which was used abundantly to describe systemic anti-tumour treatment during the last 30 days of life. Treatment for patients with incurable malignancies aims to achieve two goals: optimization of the overall survival time and of quality of life. Boddaert et al focused on a small part of this complex care. Also, quantification of quality of end-of-life-care is hard, with measurable, but suboptimal indicators as place of death, systemic anti-tumour therapy during the last 30 days of life and consultation of palliative care specialists as used in this paper.
Unfortunately, there is no optimum set for any of the indicators of (in-)appropriate care in the last 30 days of life. To aim for an as low as possible number of patients receiving systemic anti-tumour therapy during the last 30 days of their life, should not be a goal on itself. End-of-life care that actively defers from anti-tumour treatment can be potentially inappropriate too  and systemic treatme...
Unfortunately, there is no optimum set for any of the indicators of (in-)appropriate care in the last 30 days of life. To aim for an as low as possible number of patients receiving systemic anti-tumour therapy during the last 30 days of their life, should not be a goal on itself. End-of-life care that actively defers from anti-tumour treatment can be potentially inappropriate too  and systemic treatment that has been prescribed to patients in a good performance and fit for therapy according to international study standard might decease within 30 days after the last dose of chemotherapy . Weighing the pros and cons of palliative systemic treatment with the patient seems key in finding the treatment solutions for individual patients. Whether the optimal balance is found by individual clinicians might be appraised by comparison with other clinicians and clinics in similar situations.
We plea for deletion of the term inappropriate in relation to tumor-directed therapy as part of end-of-life care, as renouncing tumor-directed therapy might be as inappropriate. If palliative systemic treatment is started under conditions as stated in (international) standards, inevitably some patients will die within 30days.
1. Boddaert, M.S., et al., Inappropriate end-of-life cancer care in a generalist and specialist palliative care model: a nationwide retrospective population-based observational study. BMJ Support Palliat Care, 2020.
2. Neuberger, J., C. Guthrie, and D. Aaronovitch, More care, less pathway: a review of the Liverpool Care Pathway. Department of Health, 2013.
3. Burgers, J.A. and R.A. Damhuis, 30-day mortality after the start of systemic anticancer therapy for lung cancer: is it really a useful performance indicator? ERJ Open Res, 2018. 4(4).