A question: you are a cancer patient, faced with the following choice: four months free of chemotherapy at the end of life or six months laden with chemotherapy at the end of your life.
Which would you opt for?
Put like this it’s a difficult choice. But for all its delicacy, it’s an important discussion to have with yourself, your family and the doctor treating you. The decision isn’t about ending medical treatment, but about opting for different kinds of treatment. It is recognising that symptom control, comfort and dignity may be more important than seeking a cure.
The dilemma is the focus of a recent paper, Cancer treatment in the last 6 months of life: when inaction can outperform action, published in ecancermedicalscience – the online journal of the European Institute of Oncology. Noticing a recent trend in the regulatory approval of cancer treatments where the average survival for those treated was about six 6 months, the authors decided to look at regulatory approvals made by the US Food and Drug Administration in the previous five years. They also looked at the ethical considerations of starting a treatment that could undermine a peaceful transition from life to death.
While many oncologists will not recommend active cancer treatment when they recognise that their patients are approaching the end of life, deciding to stop chemotherapy poses a greater challenge.
So why do doctors continue to prescribe toxic therapies in the last six months of life?
“One obvious answer is that we do not know how best to predict survival – physicians are known to be particularly bad at this and they tend to be unrealistically optimistic,” the authors say. “Physicians and patients tend to have exaggerated confidence in the benefits of drugs regardless of the disease setting, despite many studies confirming the futility of chemotherapy in the last six months of life.”
By this time cancer patients will have usually undergone a series of invasive treatments including surgery, radiotherapy and drug therapy throughout the course of their disease. These limited last few months are precious for cancer patients and their families; when invasive therapy continues it leads to time being spent in hospital and enduring the toxic effects of cancer treatments rather than making the most of life.
How many patients receiving chemotherapy for incurable cancer do not realise the treatment is unlikely to be curative?
Representation of cancer drugs in the media doesn’t help: inappropriate metaphors involving “war” and “fight” abound. This makes patients with cancer feel as if the outcomes of cancer rely on their personal efforts and so they subject themselves to unjustifiable toxicities in an effort to “win the battle”. It encourages overuse of active cancer treatments past the point of futility.
Which leads to the role of healthcare professionals in negotiating the place of cancer treatments with cancer patients. The first step is for doctors to recognise that offering active treatment is psychologically a better place for them – this option is often associated with a fuller sense of professional accomplishment. Research suggests that patients too have an unrealistic perception of the stage their cancer has reached; one study found that only a small minority of people in the terminal stage of their disease is aware of their prognosis. So in-depth discussions between doctors and patients are a vital first step: the inevitable uncertainties about prognosis and the potential side-effects of continuing with active treatment must be teased out in the context of cultural and personal priorities.
Perhaps we would all benefit from a shift to a new metric such as “days spent at home in the last six months of life” to gauge the effectiveness of new cancer treatments. Such a measurement may be more meaningful and encourage better conversations than the current catch-all of “overall survival”.
There is no right or wrong answer to this column’s opening question – just better options for each individual.
mhouston@irishtimes.com