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Can there be any decision more excruciatingly difficult to make -- for doctors or for patients -- than how long to continue treatment for advanced cancer?
On the one hand, we sometimes hear compelling stories about patients who have beaten the odds despite a grim prognosis -- like the many women alive for decades after learning that they have stage 4 breast cancer, sometimes even with cancer that has metastasized to the bone. Given that the average life expectancy with this diagnosis is just 30 months, they are living testimony to the hope provided by an array of innovative cancer treatments.
But many realists, including researchers, doctors and ethicists, advise weighing the potential to buy time against the costs of extending treatment -- not just in dollars but also in quality of life. To illustrate this quandary, consider a recently developed immune modulator, sipuleucel-T (Provenge), that can help some men with advanced prostate cancer live four months longer. Staving off their lethal cancer for those additional months (if indeed it works) must be weighed against the 25% chance that the treatment will cause a serious side effect (such as stroke)... not to mention its $93,000 price tag.
How Doctors Look At It
What factors go into making such a decision? For some perspective on this painfully difficult topic, I spoke with a doctor who faces these questions often -- Thomas M. Habermann, MD, a hematologist who specializes in treating patients with malignant melanomas and a professor of medicine at the Mayo Clinic. He told me that there are four factors that doctors weigh in making treatment recommendations and decisions with their patients and families...
Cancer score: For many cancers, there is an established scoring system that measures clinical signs (such as fevers related to the malignancy) and biologic markers (such as blood tests or tumor biopsy results) to predict prognosis based on standard treatment protocols.
Type of cancer: Some cancers are harder to treat than others. For instance, advanced solid tumors of the breast, colon, ovaries, prostate and lung are less responsive to treatment than nonsolid cancers, such as leukemias and lymphomas, which often are more curable with a combination of chemotherapies even at an advanced stage.
Patient strength: How difficult will it be for a particular patient to endure the rigors (including potentially dangerous side effects) of the specific treatment being considered? Again, there is a standardized scoring system, ranging from 0 (the patient is fully active) to 4 (the patient is bedridden and needs help with most activities).
How much time? Hardest to pin down is how much time a treatment is likely to add to a patients life. This estimate considers characteristics of the cancer... whether the patient has other health issues... and statistical information based on whats known about the treatment from clinical trials and research databases. A second part of this question is to address whether the exorbitant price tag of some treatments offers significant hope for a longer life and of what quality.
Making a decision
Monetary considerations aside, patients and their families are always the decision-makers in determining "when to say when." According to Dr. Habermann, there are a few more factors that can help guide the decision:
The stage of the disease. Advanced disease gets divided further into advanced stages. Ask the doctor what stage your disease is and what each stage means, specifically with regard to pain and suffering as well as the odds of overcoming it.
Do you have personal goals to live for? Dr. Habermann says that patients who are looking forward to something specific -- such as a special wedding anniversary or family members graduation -- often have an additional incentive to try aggressive treatments.
In the end, the deciding factor in whether a patient chooses to pursue extraordinary options may be something more subjective and innate. Some patients have an especially strong will to live --- and after weighing all the options, patients often know what feels right for them.
Source(s):
Thomas M. Habermann, MD, a hematologist and professor of medicine, Mayo Clinic, Rochester , Minnesota .
On the one hand, we sometimes hear compelling stories about patients who have beaten the odds despite a grim prognosis -- like the many women alive for decades after learning that they have stage 4 breast cancer, sometimes even with cancer that has metastasized to the bone. Given that the average life expectancy with this diagnosis is just 30 months, they are living testimony to the hope provided by an array of innovative cancer treatments.
But many realists, including researchers, doctors and ethicists, advise weighing the potential to buy time against the costs of extending treatment -- not just in dollars but also in quality of life. To illustrate this quandary, consider a recently developed immune modulator, sipuleucel-T (Provenge), that can help some men with advanced prostate cancer live four months longer. Staving off their lethal cancer for those additional months (if indeed it works) must be weighed against the 25% chance that the treatment will cause a serious side effect (such as stroke)... not to mention its $93,000 price tag.
How Doctors Look At It
What factors go into making such a decision? For some perspective on this painfully difficult topic, I spoke with a doctor who faces these questions often -- Thomas M. Habermann, MD, a hematologist who specializes in treating patients with malignant melanomas and a professor of medicine at the Mayo Clinic. He told me that there are four factors that doctors weigh in making treatment recommendations and decisions with their patients and families...
Cancer score: For many cancers, there is an established scoring system that measures clinical signs (such as fevers related to the malignancy) and biologic markers (such as blood tests or tumor biopsy results) to predict prognosis based on standard treatment protocols.
Type of cancer: Some cancers are harder to treat than others. For instance, advanced solid tumors of the breast, colon, ovaries, prostate and lung are less responsive to treatment than nonsolid cancers, such as leukemias and lymphomas, which often are more curable with a combination of chemotherapies even at an advanced stage.
Patient strength: How difficult will it be for a particular patient to endure the rigors (including potentially dangerous side effects) of the specific treatment being considered? Again, there is a standardized scoring system, ranging from 0 (the patient is fully active) to 4 (the patient is bedridden and needs help with most activities).
How much time? Hardest to pin down is how much time a treatment is likely to add to a patients life. This estimate considers characteristics of the cancer... whether the patient has other health issues... and statistical information based on whats known about the treatment from clinical trials and research databases. A second part of this question is to address whether the exorbitant price tag of some treatments offers significant hope for a longer life and of what quality.
Making a decision
Monetary considerations aside, patients and their families are always the decision-makers in determining "when to say when." According to Dr. Habermann, there are a few more factors that can help guide the decision:
The stage of the disease. Advanced disease gets divided further into advanced stages. Ask the doctor what stage your disease is and what each stage means, specifically with regard to pain and suffering as well as the odds of overcoming it.
Do you have personal goals to live for? Dr. Habermann says that patients who are looking forward to something specific -- such as a special wedding anniversary or family members graduation -- often have an additional incentive to try aggressive treatments.
In the end, the deciding factor in whether a patient chooses to pursue extraordinary options may be something more subjective and innate. Some patients have an especially strong will to live --- and after weighing all the options, patients often know what feels right for them.
Source(s):
Thomas M. Habermann, MD, a hematologist and professor of medicine, Mayo Clinic, Rochester , Minnesota .