by Paul Wheatley-Price BSc, MBChB, MRCP (UK), MD
Assistant Professor of Medicine, University of Ottawa, Division of Medical Oncology, Chair of Medical Advisory Committee, Lung Cancer Canada
One of the hardest discussions between an oncologist and their patient occurs at the time of transition from active anti-cancer therapy to best supportive care alone. This consultation has been reported as one of the most stressful faced by the physician, and of course is a nodal event for the patient. It is also clear that patients want their physicians to be honest, up to date and compassionate in these meetings.
This transition point is also a point of difficulty for physicians’ clinical judgment. On the one hand, as a doctor in a branch of medicine that treats patients with chemotherapy agents, this is what we do – we treat cancer. Oncologists, with the best of intentions, are seeking to prolong survival and improve cancer symptoms with anti-cancer drugs. Yet as physicians we are also called, as our primary responsibility, to do no harm. This tension between options, particularly when chemotherapy drugs can have significant side effects, and the fitness level of the patient may be waning, makes these decision moments challenging for all concerned.
The militaristic language of cancer can also be unhelpful. We often talk in terms of a battle, being in a fight that we must win. But of course in advanced cancer, a ‘win’, seen with the ‘defeat’ of the cancer, is extremely rare. Does that mean that patients dying of cancer have ‘lost’ or been ‘beaten’ or ‘defeated’? Of course not, but unless careful we face the risk of the lack of efficacy of a treatment being framed in terms of failure of the patient, and the temptation to ‘fight on’ with further potentially toxic drugs.
It is with these considerations in mind that we can reflect on the thought provoking publication by Dr. Prigerson and colleagues in JAMA Oncology, and the challenging piece by Pam Belluck in the NY Times.
There are some methodological issues with the research that cannot be overlooked without risking throwing out the baby with the bathwater. The study was conducted a few years ago now, and the evolution of less toxic cancer therapies with higher efficacy has marched on significantly in that time for many patients. Further, the population of patients was quite mixed, which makes it challenging to directly correlate with people we see in the clinic each day. In addition, it seemed unclear how much of the deterioration reported could directly be correlated to the chemotherapy. The researchers enrolled 641 patients, but then only analyzed those who had died. We must recognize that in reporting only this group, the findings are biased towards negative outcomes. And finally, when dividing the patients into ‘chemotherapy’ and ‘no-chemotherapy’ groups, we only know that this is the situation of the patient when entering the study. As recognized by the authors, we don’t know if the ‘no chemotherapy’ group may have actually subsequently been treated, we don’t know the details of the treatments etc.
In addition, we also have access to clinical trials in a number of cancers over recent years, in patients who have progression after their first treatment, where an improvement in survival time and an improvement in quality of life have clearly been demonstrated from further chemotherapy. The clarity provided by those studies teaches us that patients can safely and successfully receive multiple lines of treatment, although limited to specific clinical populations.
So rather than taking the published work at face value, we should rather take it as research that is thought provoking, and challenging to our thinking of cancer treatment towards the end of life.
In the UK, the Gold Standards Framework is a program that encourages us to think of patients with life limiting illnesses. We ask the ‘surprise question’: ‘Will you be surprised if your patient dies in the next 12 months?’ If the answer is ‘No’ then the physician should be adopting a palliative approach to the care of the patient. What does this mean? It does not mean stopping all cancer therapy, nor does it mean immediately sending a patient to the hospice. Rather, it means recognizing that the patient has a life limiting illness, most commonly advanced cancer, and therefore initiating discussions and treatment plans with the patient around this. The physician should strive to understand the patients’ goals – is it longevity, is it purely quality of life, is there a target coming up such as a wedding, birth or anniversary? In addition, advanced care planning discussions are needed, and are generally appreciated by patients. Although a difficult subject to raise, questions about the level of care needed when the terminal decline begins have real merit. Do patients want resuscitation? Do they want to die at home? Do they have a power of attorney or substitute decision maker assigned (and communicated to those who need to know)? Some have described this as a meeting of two experts. The physician is the expert in the disease and it’s treatments. The patient is the expert in how they feel and what they want. By successfully recognizing the input of both experts, a therapeutic relationship can thrive, and plans for the best outcomes can be set in motion.
Is taking a palliative approach effective? It seems so, as evidenced by a seminal research paper led by Dr Temel, published in the New England Journal of Medicine in 2010. In this research, patients with advanced lung cancer were randomized to early palliative care input versus the normal pattern of referral towards the end of life. The results were startling, with those randomized to the early palliative approach experiencing higher quality of life, a reduced chance of being admitted to the intensive care unit or attending the emergency department, and remarkably they also had a significantly longer survival.
So what can ultimately be concluded from these interesting pieces of research? Maybe as clinicians we should remember that, perhaps, care is more important than treatment.