I don’t think there is any diagnosis in all of medicine that conjures up more fear in patients and families alike than the diagnosis of cancer.
I suppose such fear is at least somewhat justified given that president Richard Nixon declared a war on Cancer in 1970 and despite there having been more research dollars spent on cancer than any other diagnosis in the history of medicine we have still, in 2015, made very little progress toward the eradication of most cancers.
My Personal Experience
This topic became near and dear to me recently, when the father of a close friend was diagnosed with terminal cancer of the Bile Duct. He was initially offered radiation by a local oncologist in Brooklyn but then sought a second opinion at Sloan Kettering and was told neither radiation nor chemotherapy would offer him any benefit. If it hadn’t been for the fact that the initial oncologist lost the trust of his family by being less than straight forward during the diagnostic process, he probably would have undergone useless radiation that may have hurt more than helped.
I must admit, when they told me they were going to Sloan for a second opinion I was fearful that he would end up dying of chemotherapy instead of dying of cancer, but to their credit, the physicians at Sloan were very straight forward and let the family know that the prognosis was very poor and that they had no treatment that would extend his life or improve the quality of his remaining life. Although that is a very bitter pill to swallow it gave the patient and family the opportunity to begin to emotionally process the inevitable, without the emotional and physical pressures of undergoing futile treatments.
I submit that this approach is not only more humane but just a better use of resources, both the patient’s as well as the health care system’s and it seems that the oncology community is finally beginning to agree.
Research Supports No End of Life Chemo
A recent article on Medscape entitled Palliative Chemo Worsens Quality of Life in Dying Patients discusses new research that indicates that forgoing chemotherapy in patients with 6 months or less of life expectancy affords patients a better end of life experience. The article sites a recent study in which the researchers looked at chemotherapy use, performance status and quality of life at end of life.
Currently the American Society for Clinical Oncology guidelines recommends palliative chemotherapy only for patients with solid tumors and good performance status. This means it is offered to patients who are the most well, with the thought being that those are the patients who would most likely be able to withstand the rigors of the treatment given their stronger physical condition, despite the fact that they still have a very poor prognosis with less than six month life expectancy.
The study showed that in fact, this group of patients actually fared the worst. It showed that patients who were the sickest and those who were moderately sick and received chemotherapy got no improvement in quality of life during their last week of life, and patients who were the most well (or ranked as having good performance status) and received chemotherapy actually got worse during their last week of life.
I found it interesting that in much of the commentary that was submitted in response to this study, the sentiment was that many oncologist had already felt that offering chemo in these circumstances was not the best thing to do, but felt pressured either by patient and family demands, or felt as though withholding chemo in these instances deprived the patient of all hope for improvement.
The question I ask is, what happened to the oath we took to do no harm? It is understandably a difficult conversation to have with a patient and family who are looking to you for help but I submit that truth always trumps everything else. And if the truth is that chemotherapy will cause more harm than good, than the truth should be told. What better time than this, to leverage the trust that the patient and family have placed in you and do the right thing.
These are issues that I think we, as integrative practitioners are well suited to navigate. We already operate from a premise of do no harm and we tend to focus on the person as a whole, understanding not just their physical condition but also their spiritual condition and how their interpersonal relationships affect their views on life and death.
Integrative practitioners who work with cancer patients often take criticism from conventional medicine, being accused of using quackery to prey on poor desperate unsuspecting cancer patients. This is one area of oncology where I believe the tables may be turned. Perhaps the problem is not just that conventional oncologists are lacking a solution to their patient’s problem but that they are lacking the ability to articulate that fact effectively.
What’s your view? Leave me a comment and let me know.