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! I am going to write several articles based on this topic and the article by Minster et al in JCO!
To Be Optimistic or To Be Honest?
I routinely see patients with metastatic melanoma and metastatic pancreas cancer and the last decade has seen tremendous progress in the melanoma world where what used to be a “6 months to live” situation has now turned into nearly half of the patients are alive without disease recurrence. Unfortunately, this is not the case in the pancreas cancer world. Sure, there have been modest gains for pancreas patients but nothing as meaningful as has been seen with all the new immunotherapeutic drugs for melanoma or other immune-sensitive tumor types.
As an oncologist, I am a “half glass full” when speaking to melanoma patients speaking cautiously optimistic for the patients who are treatment naïve with giving the test of time and seeing where the road will go. Nearly half of all metastatic melanoma patients can achieve long term durable response/remission off all treatment.
Ten years ago, this was not the case at all! Back then, 5% of metastatic melanoma survived long term if and only if they had high dose toxic IL2 which required an admission to the hospital and a short stay in the ICU after taking up to 14 rounds of a brutal treatment leading to respiratory distress and shock requiring ventilatory and blood pressure support respectively. Again, all that for a 5% chance of long term remission! Today, nearly 40-50% can achieve a radiographic response with outpatient treatment using intravenous therapy that may or may not cause adverse immune effects. Certainly, I am more honest with these same patients if we find that we are not winning the battle despite 2-3 treatment attempts or if the patient suffers a significant decline in status to forego further treatment.
For pancreas cancer patients, I cautiously tend to be more honest upfront. I think it is so important to be honest in order to set expectations for the patients and family while certainly arming them with information to get their affairs in order and making the best use of their limited time while they remain ambulatory and in reasonable shape. In these situations, I sincerely hope I am wrong about the prognosis. I will continue to fight and give the best treatments or clinical trial options we have or refer to another cancer center if clinical trial options are not available at our center. And certainly, we are all pleasantly surprised if patients are doing well or better than expected with standard treatments or perhaps newer treatment options. The biology of the disease or treatment response can be vary widely with patients.
No matter how it goes, if patients and families want to know their prognosis, then they can rightfully ask for this information and I believe we as their oncologists will have to do our best to state this to the patient and their families as honestly as we can while not completely taking away their hope upfront. What if they have actionable mutation such as NTRK, BRAF, BRCA or high TMB or MSI-H where targeted therapy or immunotherapy become good options to consider more so than chemotherapy? What if they participate in a new clinical trial offering an innovative treatment option with durable response such as cellular therapy or newer forms of chemotherapy/immunotherapeutic/targeted therapy/intratumoral therapies? What if they have platinum sensitive tumor types and here they are 2 years later still taking an oral PARP inhibitor to keep their disease at bay or after maximal platinum response?
On the flip side, once a patient goes down the slippery slope of progressive treatment-refractory disease, then they tend to lose weight, nutrition, ambulation, cognition which are all highly likely the symptoms of end stage cancer and where survival is typically measured in weeks to 1-2 months at best. It becomes unethical to continue futile and harmful treatments. At this point, I am very honest with patients and their family. I tell them to just take it one day at a time. Focus on what they can control daily with activity, nutrition, mindset, and time best spent with their family and loved ones in what is likely their last days. But even then, no matter how small, I always hope and remain cautiously optimistic that they will physically rebound back to fighting their disease again in clinic. Some do! While most days, I will always say never give up.. never give in, there are times we just need to be honest.
Let me know what you think.. agree or disagree? If you’re a patient or caregiver, please feel free to share your story.
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.