Our cancer care system IS in crisis, and …

… the situation is laid out in some detail in an article by Payne and Dale on the Health Affairs blog site. Additional commentary can be found on the Medscape Oncology site.

The bottom line is quite simple. It is a fallacy to think that everyone who receives any type of diagnosis of “cancer” is going, necessarily, to benefit from aggressive treatment. It is utterly inappropriate to treat all patients with a cancer diagnosis aggressively based on such a belief. And we need to realize that people with a diagnosis of cancer don’t suddenly stop being at risk for a whole bunch of other disorders that may well have greater impact on their quality of life than their cancer.

Last but not least, as we all get older, we all become less healthy. There comes a point at which “less” is very definitely “more” — not more in terms of an extra month or two of life, but more in terms of the quality of that remaining life, and not less in terms of the quality of the care we should receive, but less in terms of the aggressiveness of that “care”, the side effects associated with that “care”, and the costs we all have to pay for the outside chance of that extra month or two of survival with all of the complications and side effects.

Payne and Dale lay out a proposed set of relatively simple steps that we all need to think about as healthcare advocates (for ourselves and for others too). There absolutely are some patients for whom highly aggressive cancer therapy is highly appropriate. And then there are many others whose chance of benefiting from such aggressive therapy is so tiny by comparison with the potential complications and side effects of treatment (regardless of the cost factor) that one really has to ask whether it is wise to roll the dice at all.

In the field of prostate cancer, at least, we have started to address this problem — with greater emphasis on things like active surveillance and other forms of expectant management. However, we still have a long way to go. And the re-orientation of the world of cancer medicine towards quality of care for each individual patient as the overall priority (as opposed to elimination of the cancer itself in all patients) is going to take years to accomplish.

3 Responses

  1. Is it supposed to be obvious that “There absolutely are some patients for whom highly aggressive cancer therapy is highly appropriate” and how these patients are recognized? It’s not obvious to me, though of course it must be so. Anyway, it’s odd to read this sentence and not see some suggestion of the recognizable characteristics of patients suitable for “highly aggressive cancer therapy”. I thought PSA doubling time — although I’ve never seen a straightforward interpretation of this in the literature (that is: what doubling rate?), and my oncologists don’t seem to be alarmed by my 1-month PSA doubling time. Are they just trying not to scare me unnecessarily, as long as my ADT (Lupron + bicalutimide and now enzalutimide) is working?

  2. Grover:

    The precise reasons why one man may absolutely need aggressive treatment and another may not run on a scale (as if from 0 to 100) and can only be determined by the individual characteristics of the patient and his specific situation. However, …

    At one extreme is the 95-year-old man who (for some bizarre reason) is diagnosed with early stage, low-risk prostate cancer with a PSA of 3.5 ng/ml, a Gleason score of 6, and 1/12 biopsy cores positive for cancer with only 5% of that single core showing signs of any cancer. He also has chronic heart failure and diabetes. Aggressive therapy for such a man would be nuts. Indeed, it would actually be nuts for him to have been diagnosed at all since he is much more likely to die of a heart condition than his prostate cancer which is probably indolent anyway.

    At the other end of the scale is (say) an otherwise very fit and healthy 45-year-old male diagnosed with a PSA of 8 ng/ml, a Gleason score of 9, with 5/12 biopsy cores positive for cancer. If this man is to have any reasonable hope of living to 60 he almost certainly needs urgent and aggressive therapy.

    With respect to your personal situation, I would have to have a lot more information to be able to make any sort of informed comment. However, what I can tell you is that if I had a PSA doubling time of 1 month while on an LHRH agonist, an antiandrogen, and enzalutamide, I would be more than a little concerned, and I would hope that my oncologist was too.

  3. The hardest part and thing to accept in my cancer experience is that I had to fight tooth and nail to try to get some treatment.

    From a routine blood test I learned that my PSA was 300. I live in a very isolated area in the mountains of British Columbia, Canada. My GP does not wait for the local urologist to come back from holidays, she schedules a bone scan for the next Monday. It comes back lit up like a Xmas tree (30+ metastases all over my bones).

    I finally see the urologist that Friday and he tells me the blurb that prostate cancer is not dangerous, prostate cancer is slow moving, I probably had that prostate cancer for years. There is no rush. I will be scheduled for a biopsy in 2 to 3 months, then the results will come 2 weeks later. Then and only then will I be allowed to see an oncologist.

    Let me tell you that I moved heaven and earth to accelerate the process. Everything that I was reading was confirming that my treatment should start right now.

    I finally succeeded in accelerating the process a little bit and I saw the oncologist after “only” 5 weeks. By then my PSA had gone from the initial 300 to 560. … Talk about doubling time!.

    My fight with the medical system has been the most challenging episode of my prostate cancer experience.


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