To be good physicians, we must all fight against the battle against cancerBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5862 (Published 30 September 2014) Cite this as: BMJ 2014;349:g5862
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Towards development of a decision tool in the multidisciplinary instead of military approach of the battle against cancer.
McCartney (1) and Berger (2) righteously raise the issue of turning decisions regarding initiating, withdrawing or stopping palliative tumor-directed treatment of advanced cancer into a military battle for the patient involved. In addition to fundraising institutes such as CRUK, using slogans such as “Be ready to fight”, in the Netherlands a fund raising institute called Alpe D’Hu6, uses the slogan “Giving up is no option”. This organisation has raised an enormous amount of money which is being used to carry out quality of life studies in this population in the Netherlands, which is a very usefull contribution to oncologic care . As oncologists, however, we are faced with patients in stages of cancer in which that fight or battle is inappropriate and giving up may be the very best option.
The decision whether or not to initiate or stop palliative tumor-directed treatment is very complex. Patients, while adequately informed by the oncologist and or physician assistant, do not always understand the treatment options, adverse events and its consequences. Even if they do, it remains difficult to apply data regarding response rates, duration of response and survival to themselves. Frequently they are somehat prejudiced by histories of relatives or acquaintances, who have or had cancer and underwent treatment and eventually died nevertheless, especially if they perceived poor quality of life. Response rates, duration of response and toxicity may be predicted based on underlying cancer, WHO performance status and co-morbidity. Eventually, the motivation of the patient is crucial. This, in turn, is dependent on information exchange regarding the factors described above, with emphasis on (maintenance of) quality of life.
In advanced melanoma the outcome has improved due to developments in immunotherapy (eg ipilimumab) and targeted therapy (eg BRAF inhibitors) (3). Both strategies are determined to be cost-effective by NICE (4,5). Until quite recently, dacarbazin was the only registered drug used in this disease. At that time, a young patient, intensely willing to survive, faced the option of supportive care only or chemotherapy with a very low response rate, duration of response, hardly any prolonged survival and generally a modest tolerance, depending on the performance status at start. Why did certain patients have any motivation despite this poor profile, provided they were adequately informed and understood the consequences ? Clearly, I would agree not to apply the military metaphore, as described and criticised by McCartney and Berger here. But what if this patient was going to be father within three months, I believe many would agree on giving him the benefit of the doubt. Yet, a clear frontier is difficult to establish if we introduce such factors. In the era of immunotherapy and targeted therapy in advanced melanoma the eventual faith is not different. Nevertheless, we can provide treatment resulting not only in prolonged survival, but also in quality of life, especially BRAF inhibitors in those who are BRAF V600 mutated (3). So, the odds for patients are better now, at least temporarily, but the dilemma regarding continuing or withdrawing palliative tumor-directed treatment inevitably comes.
In my opinion it is important to establish an objective decision tool using scores of the various disease-, patient- and doctor-related factors involved in order to facilitate this decision process in addition to existing estimation of these factors as well as doctor’s expertise and experience regarding the cancer involved. After its validity has been determined in future studies, all cases should be debated in a multidisciplinary meeting, including the general physician. In addition, early introduction of non-tumor-directed palliative care, ie before, during and after tumor-directed treatment, delivered by palliative care specialists is mandatory, as it is associated not only with improved care but sometimes also with cost-reduction (6). The advise hence formulated might facilitate the decision made by the patient. In addition, it may balance the impression that we, as overenthusiastic medical oncologists, even dig up corpses for additional chemotherapy cycles.
1. McCartney M. The fight is on: military metaphors for cancer may harm patients. BMJ 2014: 349:g5155
2. Berger DW. To be good physicians, we must all fight against the battle against cancer. BMJ 2014;349:g5862
3. Grob JJ, Amonkar MM, Martin Algarra S, et al. Patient perception of the benefit of a BRAF inhibitor in metatstatic melanoma: quality-of-life analyses of the BREAK-3 study comparing dabrafenib with dacarbazine. Ann Oncol 2014;25:1428-36
4. Hall CJ, Dass S, Robertson J, Adam J. NICE guidance on ipilimumab for treating previously untreated advanced (unresectable or metastatic) melanoma. Lancet Oncology 2014;15:1056-57
5. Beale S, Dickson R, Bagust A. et al. Vemurafenib for the treatment of locally advanced metastatic BRAF V600 mutation-positive malignant melanoma: a NICE single technology appraisal. Pharmacoeconomics 2013;31(12):1121-9
6. Parikh RB, Kirch RA, Smith TJ, Temel JS. Early specialty palliative care. Translating dta in oncology into practice. N Engl J Med 2013;369(24):2347-51
Competing interests: No competing interests