Cancer care: Too much and too little

Cancer care: Too much and too little

There were two disturbing reports from the American Society of Clinical Oncology that seemed to suggest opposite problems.

From MedPage Today:

Many patients with early-stage non-small-cell lung cancer (NSCLC) never see a medical oncologist because their primary care physicians don’t think chemotherapy can help them.

And from Modern Healthcare:

Cancer care for patients who are near death is becoming more aggressive, with doctors ordering chemotherapy and other medicines in often futile attempts to extend lives, according to a study by Harvard Medical School researchers. Doctors should review their treatment regimens and in some cases focus on palliative care for patients in the last days of their lives instead of on costly medicine, the researchers said.

Both problems are serious and –based on my experience– real. I think they may also be related. A relative of mine was initially denied chemotherapy for leukemia –because the doctors thought he was too old. Turns out that age wasn’t really a legitimate factor, based on the evidence, and when we fought for chemo he responded well and lived another 10 months with a reasonable quality of life. At the end, we opted for palliative care and he didn’t go through a useless and painful regimen.

But patients and families can be forgiven for pushing for aggressive care –even that which the researchers deem “futile.” Not everybody wants to go down without a fight, and patients may have it in the back of their minds that their doctors are performing a cost/benefit analysis on them and deciding it’s not worth the effort for a small chance of recovery or that the doctors may not really know what works. By the time a patient works his way through the system and finds an oncologist who will treat him, it may also be too late for the standard protocols.

Finally, with all the new cancer drugs in development there’s going to be even more aggressive late-stage treatment, much of it futile.

June 5, 2006

4 thoughts on “Cancer care: Too much and too little”

  1. Both reports illustrate the importance of finding an excellent primary care physician who will continue to advocate for a patient throughout a serious illness (whether the diagnosis is cancer or other life threatening disease). On the one hand, it is crucial to have a primary care physician who is aware of the available therapeutic options for all serious illnesses, and who knows when it is appropriate to seek non-curative options.
    In my experience, the primary care physician may be able to keep the “big picture” in a more clear focus and facilitate the appropriate level of care. With notable exceptions, oncologists have a tendency to push for therapeutic options (chemo/radiation etc…) when the a shift to a more palliative approach is appropriate. A good primary care physician with a strong relationship to the patient can act as a “quarterback” and arrange for the appropriate transitions between specialists.

  2. I agree with your premise, but we need to take a broader view. Its virtually impossible for the average patient to find a wholly supportive, primary. The majority of our population are left to find their own ways, when dealing with the threat of a life-threatening condition–not fair. We’ve got to do something about this, and fast. Educating medical colleagues is the first and foremost way to really care for the total person.
    At the same time, the public must be repeatedly informed (in many venues, direct, brochures, advertising, logos, mottos, etc) that they have options for second, third, fourth opinions (NIH is no cost to the public), and that their healthcare professionals will do everything possible to help facilitate their decisions, or present difficult cases to their own peers.
    Its time to invite the patient into a team approach, even those who may prefer to let everything rest in their physicians courts (no pun intended, but that is a potential when the patient is not involved in all communications).

    Good comments–

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