In an article in today’s (April 22) New York Times Sunday Review section, a physician named Robert M. Wachter writes about what he calls “The Problem with Miracle Cancer Cures” This problem is that the cures are just good enough to tantalize people without being good enough to make a real difference to most patients. Specifically, he says, “[a] recent analysis estimated that about 15 percent of patients with advanced cancer might benefit from immunotherapy – and it’s all but impossible to determine which patients will be the lucky ones.” So patients lured by the likely illusory promise of the new treatments will continue seeking a cure for their disease when they should be focusing on palliative care, with which they can live their remaining time with more comfort and might even wind up living longer.
Dr. Wachter’s concrete recommendations for what to do about
this are fine – he wants to encourage patients to combine palliative and
curative approaches; to train doctors to better discuss the pluses and minuses
of the choices patients now face; and to press research that will identify
those patients for whom the new treatments really might be curative.
But his attitude nevertheless grates. He writes that “by
blurring the line between cure and comfort – and between hope and hopelessness –
they [the new treatments] have disrupted the fragile equilibrium that we
doctors have long taken for granted.” And he cites the case of a woman in her
80s, “clearly dying of lung cancer,” whose family asked about immunotherapy. He writes: “When
I reluctantly asked our oncologist about this, he didn’t scoff. ‘It could work,’
he said quietly, as if not quite believing what he was saying.”
What’s most striking about this story is Dr. Wachter’s
reluctance even to ask. Why is he so reluctant? Put objectively, the reason
seems to be that his patient might then try immunotherapy – which “could work” –
instead of focusing, as apparently he feels she should, on palliative care
since she’s “clearly dying.” There’s an obvious response to this: it’s the
patient’s life. And it’s not clear that patients, clearly presented with the
relevant facts, are actually unable to make sensible decisions about their
lives, and deaths. Nor is it clear that the best decision, measured on some
objective basis and then imposed on the patient without her full and knowing consent,
is actually “the best”: there are a lot of arguments against paternalism, though my impression is that some doctors don’t seem to be convinced by them.
To be fair, Dr. Wachter says, and I don’t doubt it, that “[w]e
already know that despite the unquestioned value of hospice, many patients with
end-stage cancer don’t take advantage of it, or do so with only a few days left
in their life, having needlessly suffered for weeks or months.” This may be a
sign of patient irrationality, though it may also be a sign of poor
doctor-patient communication. It might be the result of insurance problems, as
Teresa’s pointed out. Or it may reflect that many doctors, unlike Dr. Wachter,
are themselves committed to what he calls a “pugilistic approach to cancer.” (I’m
sympathetic to those doctors; I’d rather be cared for by one of them than by
the opposite, whom we might call a cancer appeaser.)
In any case Dr. Wachter’s approach doesn’t seem to be
motivated by just the objective concern about the making of wise treatment
decisions. There is emotion here too, in his “reluctance” even to ask the
oncologist about immunotherapy. He also tells us that before the advent of
immunotherapy, when patients would sometimes ask him about the option of
palliative care, while “the conversation is often heartbreaking, it has rarely
been a hard call.” And then he adds: “But now it is.”
Dr. Wachter is clearly a caring person, and I don’t mean to
suggest otherwise. (According to Wikipedia, he’s a leader in improving hospital care and with a
colleague coined the term “hospitalist” to describe his focus.) But it seems
fair to say that he himself is distressed by the emergence of these new
treatments; they disrupt not only patient choices but doctors’ equilibrium. Before, he knew what to say; now, it seems,
he still feels pretty strongly about what to say – that for most patients the
new treatments are not going to help – but what he wants to say is no longer as
persuasive to the patients. Moreover, what he would have readily said in the
past is no longer as persuasive even to
him. In 15 % of cases (to use the number from the study he cites), his
advice to turn from treatment to palliation would be quite wrong. The arrival
of treatments that give a modest degree of hope makes matters unclear and
advice uncertain, and the result is hard for doctors as well as patients.
I have been fortunate (sort of!) in my illness; for almost two and a
half years I’ve been treated with chemotherapy, with relatively mild side
effects. I don’t face the hard choices about palliative care, with or without
further treatment designed to fight my cancer, that Dr. Wachter is describing. And
I do understand (even if only somewhat abstractly) that cancer doctors, who
care for patients whose prospects are often grim, have a job that can be
emotionally wrenching on a regular basis. That said, I can’t say that I share
Dr. Wachter’s seeming dismay at the emergence of new, but limited, hope. Let
hope spring eternal! I’ll do my best to make careful choices based on the data;
as my wife Teresa says, this is something that cholangiocarcinoma patients are
experienced in doing. But give me a doctor who rejoices in new hope rather than
being dismayed by it, any day.
Well said
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