Delaying Palliative Chemo May Improve QoL Without Affecting Survival for Asymptomatic Patients

M. Alexander Otto, PA, MMS

August 30, 2023


Holding off on palliative chemotherapy until symptoms start appears to improve quality of life (QoL) without affecting survival for asymptomatic patients with advanced cancer.


  • Traditionally, chemotherapy is started immediately when advanced cancer is diagnosed, but delaying chemotherapy until symptoms start could improve QoL.

  • To find out, investigators performed a meta-analysis of five studies that explored the timing of palliative chemotherapy. The analysis included three randomized trials in advanced colorectal cancer (CRC), one in advanced ovarian cancer, and a review of patients with stage IV gastric cancer.

  • Of the 919 patients, treatment was delayed for 467 patients (50.8%) until symptoms started in the colorectal trials. It was delayed until tumor recurrence in the ovarian cancer trial, and it was delayed until a month or more had passed in the gastric cancer study, regardless of symptoms.

  • QoL was assessed largely by the EORTC-QLQ-C30 questionnaire. Median follow-up ranged from 11 to 60 months.


  • The researchers found no significant differences in overall survival between patients for whom chemotherapy was delayed and those for whom chemotherapy began immediately (pooled hazard ratio [HR], 1.05; 95% CI, 0.90 – 1.22; P = .52).

  • Median overall survival was 11.9 to 25.7 months with immediate treatment, vs 9 to 27.1 months with delayed treatment.

  • In the three studies that evaluated QoL, the findings suggested that QoL was largely better among patients whose treatment was delayed. In the CRC studies that assessed QoL, for instance, global health status in the delayed treatment group was higher than that in the immediate treatment group at almost all time points, but not significantly so.

  • Rates of grade 3/4 toxicities, evaluated in two studies, did not differ significantly between the groups.


  • There is limited evidence on the optimal timing for starting chemotherapy for asymptomatic patients with advanced cancer. In these studies, delaying chemotherapy until symptoms occurred did not result in worse overall survival compared with immediate treatment and may have resulted in better QoL, the researchers concluded. They note that for asymptomatic patients, delaying the start of systemic therapy should be discussed with the patient.


The study, led by Simone Augustinus of the University of Amsterdam, the Netherlands, was published online August 17 in The Oncologist.


  • Only three types of cancer were included in the analysis, and the findings may not be generalizable to other types of cancer.

  • Some of the studies were older and employed out-of-date treatment regimens.

  • QoL was only evaluated in 3 of 5 studies and could not be evaluated overall in the meta-analysis because of the different time points measured in each trial.


  • The study received no external funding.

  • Two investigators have advisory, speaker, and/or research ties to Celgene, Novartis, AstraZeneca, and other companies.

M. Alexander Otto is a physician assistant with a master's degree in medical science. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape and is an MIT Knight Science Journalism fellow. Email:

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