Oncologists face many ethical challenges in their practice, including balancing honesty and optimism, aggressive and careful treatment, appropriate treatment for the elderly, and when to refer patients to hospice. Telling patients the truth about their diagnosis and more importantly the prognosis while also providing hope can be difficult, as can balancing the intensity of treatment with the potential for toxicity. Geriatric oncology presents additional challenges as treatment decisions must balance the best outcome with reduced toxicity. Decisions on when to refer to hospice can also be challenging as patients may not be ready to accept it, but prognostic models and goals of care can guide these decisions. Oncologists must navigate these complex ethical considerations to provide the best care for their patients. A lot of this was summarized well by David Minster in JCO published way back in 2013 and a decade later, I still refer to this same article to this day! This article is 2nd in a series of blog articles on this topic.
To Be Aggressive vs To Be Careful
As an oncologist, one of our primary responsibilities is to help our patients overcome their illnesses and regain their health. However, in oncology, the treatments we use to fight cancer can also cause significant harm to our patients. This is why it is essential that we find a balance between being aggressive with our treatments versus being careful not to cause unnecessary harm.
One of the first questions we ask when seeing a patient is “what is our treatment intention”? Are we treating to cure the patient or are we treating to palliate the symptoms and/or slow the disease down or keep the disease at bay for as long as we can? If the disease is curable then we as health care providers as well as patients/families are willing to take on potentially toxic therapy for at least a 5-10% chance of cure long term. A large benefit with minimal side effects would be ideal. But what if low odds for response with high risk for adverse effects? If we are going for the cure especially for young or healthy patients, we will be aggressive.
Let’s maintain the standard dosage and treatment schedule to be on point and replicate the best long-term outcomes for remission that prior clinical trials had demonstrated and proven. For example, prior to all the new therapies that we now have, a young healthy patient with Stage IV Metastatic Melanoma a decade ago had only two treatment options. Chemotherapy to control the symptoms/disease or an aggressive option of using High-Dose IL2 which required up to 14 doses of inpatient treatment where each dose eventually led to respiratory distress/low blood pressure requiring a short ICU stay for ventilatory and pressor support, respectively. Young healthy patients did this aggressive form of treatment for a 1 in 20 chance of long-term remission.
That is a 5% long term chance of cure?! If you were young with family, we really had no other better option. If you were elderly, we would never consider this aggressive therapy. Today, we have much better treatments for melanoma patients and patients now have a 1 in 2 chance of long-term remission with either checkpoint inhibitors, TILs, intra-tumoral therapies, and/or newer innovative treatments under clinical trials. We are willing to take on greater toxicity risk or I often candidly say “spicier options” to achieve our chance for long term remission.
The intent to cure is not dependent on the stage as many patients may sometimes think. It is possible to have a Stage IV metastatic colon cancer, sarcoma and still have a treatment intention of cure for the long term. Stage IV colorectal/sarcoma malignancy with limited resectable disease to the liver and/or lung? Yes, curable intention! I have patients who are 10 years out from surgery, chemotherapy, and/or targeted radiotherapy or ablation. If patients have limited disease, then we will take on the risk of surgery or ablation with potential infection, wound healing, anesthesia, clots, leaks, etc.. to achieve radiographic remission and hope with periodic scans over time, we do not see new tumors showing up or the need for using chemotherapy.
However, often we know that any of the treatments we have in our arsenal will not necessarily cure the disease. Or if we give the “test of time”, the disease will declare itself unexpectedly with diffuse multi-focal disease as an incurable condition. Then in these situations, the 1st goal for the patient is their quality of life and the 2nd goal is to slow the disease without compromising the first goal. In other words, let’s make sure the treatment is not worse than the disease. Let’s make sure we mitigate the side effect risk to the patient and then control the disease without compromising their quality of life. Let’s control their symptoms first then focus on improving their survival. Let’s not take on unnecessary risks. We will prefer to consider palliative procedures with “light-dose” radiotherapy or palliative surgical resections or interventional nerve blocks to improve their symptoms before embarking on “light-dose” systemic treatments.
Sometimes, patients may have what appears to be a “curable” disease in the “ideal” patient but the patient is too elderly, too co-morbid with other medical issues (heart failure, neurologic compromise with prior strokes, end stage renal disease or end stage liver disease), or the patient preference is to be conservative as opposed to aggressive with their treatments. Then we will need to have an honest conversation! For example, for Stage III Esophageal or Gastric or Rectal cancer, it often takes a combination of radiation, chemotherapy and surgery to achieve the best outcomes of long-term remission. But if the patient is 95 years old or has severe heart failure or cirrhosis with a limited lift expectancy, then it is likely the treatment we administer may be worse than cancer. Assuming no reasonable compromise to mitigate the risk with curative intent treatment, the risk of surgery or targeted full dose radiotherapy may outweigh the risk of the cancer to limit the patient’s life. Drug therapy will only slow the disease in most situations with few exceptions (i.e. immunotherapy for MSI or High TMB)
Being a physician involves constantly balancing the need to be aggressive and the need to be careful. We want to help our patients as much as possible, but we also need to keep their well-being in mind as well as their preferences for how they would like to live knowing the potential risk/benefits of treatment. Striking the right balance can be challenging, but it is essential for providing the best care possible for our patients. Let’s be aggressive to optimize cure but let’s also be careful to mitigate the risk.
Let me know what you think? Please feel free to ask questions as these topics are complicated. Please feel free to share your story or experience!
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.
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