By Richard C. Frank, MD
When it comes to treating cancer, there are several potential issues that may reduce the quality of care for patients and their loved ones. These may not be considered when first making treatment decisions and can be regarded as cancer care pitfalls. Consider the following story:
A 70-year-old man learned he had stage IV colon cancer that had spread to his liver, lungs and bones. This situation is incurable, but the man chose to drive more than an hour away several times a week to a prestigious medical center rather than receive the same chemotherapy close to his home. After nine months, his condition deteriorated, requiring him to be admitted to his community hospital. He promptly requested that his care be transferred to an oncologist close to home, but his cancer was too advanced and hospice care was most appropriate. Unfortunately, the patient and his family had not been told this by his oncologist and had not thought about end-of-life care. He died two days later in a hospital bed 10 minutes from his house.
This vignette illustrates some of the pitfalls that await cancer patients as they journey through the maze of cancer care. These pitfalls highlight important deficiencies in our cancer care delivery system, but the good news is that most of them are avoidable.
Pitfall #1: The belief that further is better
Certain cancer surgeries are better performed at high-volume cancer centers, but there is no evidence that outcomes for chemotherapy or radiation are superior at these centers. The National Comprehensive Cancer Network acknowledges that chemotherapy is expertly delivered in the community and that quality of life and distress are very important considerations when selecting where to receive treatment. Because cancer treatments are often toxic and time consuming, unnecessary travel can make the situation worse. A second opinion (see my previous blog) can provide peace of mind that the treatment received close to him is the right one. For less common cancers, a second opinion is essential.
Pitfall #2: Failing to discuss prognosis
Although people are living longer with the advanced stages of cancer, the most common types remain incurable. Yet, too many oncologists fail to discuss prognosis until all treatments have been exhausted. Some of these treatments are futile and time would be better spent focusing on living each moment to its fullest rather than putting false hope in yet another treatment and dealing with side effects. Some families fear that talking about dying will cause their loved one to lose hope. This is not true. Research has shown that most patients do not lose hope when they are made aware of the reality of their situation, which they often suspect. (Doctors should respect the preferences of those who choose not to know their estimated prognosis.)
Pitfall #3: Focusing on treatment only
When cancer is first diagnosed, it is natural to spring into attack mode and go to any lengths for what is perceived as the best care. But it is a disservice to not understand the many needs of a cancer patient and the factors that go into great cancer care. These include much more than surgery, chemo and radiation. Treating a patient requires compassion and a community of caring, from oncologists who guide the patient and their loved ones throughout their cancer journey to psychosocial support and spiritual guidance, provided by family therapists, social workers, clergy and other counselors.
Pitfall #4: Being unaware of options
Cancer research is accelerating. No one center has all the available options. Increasingly, the average oncologist in a community-based practice may not be aware of the many emerging experimental options in a particular cancer. These include clinical trials targeted to specific genetic changes harbored by an individual’s cancer. This type of personalized cancer medicine is greatly expanding the options for patients with incurable cancers. Fortunately these types of trials are becoming more prevalent in both community-based and university-based cancer centers.
In a world with an abundance of choices for cancer care, in which we obtain multiple opinions and are inundated with advertising, the informed patient who is aware of the potential pitfalls will be the most satisfied with his or her care and experience the best outcome.