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Whose choice is it?


Laura Ann

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Doctors say futile cancer treatment rising By MARILYNN MARCHIONE, AP Medical Writer

Fri Jun 2, 7:35 PM ET

ATLANTA - Doctors are reporting a disturbing rise in the number of cancer patients getting chemo and other aggressive but futile treatment in the last days of their lives.

Critics of the practice say doctors should be concentrating instead on helping these patients die with dignity and in comfort, perhaps in a hospice.

Nearly 12 percent of cancer patients who died in 1999 received chemotherapy in the last two weeks of life, a large review of Medicare records revealed. That is up from nearly 10 percent in 1993, and the percentage probably is even higher today, researchers said.

"Patients don't like to give up," and neither do physicians, said Dr. Roy Herbst, a cancer specialist at the University of Texas' M.D. Anderson Cancer Center in Houston who had no role in the study.

Overly aggressive treatment gives false hope and puts people through grueling and costly ordeals when there is no chance of a cure, cancer specialists said.

"There is a time to stop," said Dr. Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical School. "It's sometimes easier to just keep giving chemotherapy than to have a frank discussion about hospice and palliative care."

Earle led the federally funded study and presented the findings Friday at a meeting in Atlanta of the American Society of Clinical Oncology.

He examined Medicare records on the care of 215,488 people who died of cancer in the 1990s.

Admissions to hospital intensive care units in the last month of life climbed from nearly 8 percent in 1993 to 11 percent in 1999. Emergency room visits rose from about 24 percent to more than 28 percent.

The number of cancer patients entering hospice in the last three days of life also rose, from roughly 12 percent to 15 percent.

"That's like a waste of the whole hospice process," which stresses preparing the patient emotionally and physically for death, Herbst said. "People have to be ready to do that."

Part of the problem is that doctors cannot predict how soon an individual patient will die, even when they know the cancer has spread widely and is incurable.

The study found variations around the country in how aggressive doctors were, but researchers would not give specifics.

This study focused on traditional chemotherapy and was done before newer medicines like Herceptin, Avastin and Gleevec, which more precisely target cancer, came into wide use.

"They're clearly not as toxic as the chemotherapy," so a patient's quality of life may not be harmed by late treatment with these drugs, Earle said.

Still, Ellen Stovall, president of the National Coalition for Cancer Survivorship, said doctors and patients have to be more realistic.

"I see, in cancer care, so much treatment being used in the last three months of somebody's life that doesn't really help," she said.

However, another study presented at the cancer meeting on Friday showed the opposite problem: people not getting enough care.

A survey of nearly 700 primary care doctors in Wisconsin found that only 11 percent would refer a patient with advanced lung cancer to a cancer specialist and only 25 percent would refer a woman with advanced breast cancer.

"We also found a general lack of knowledge about the benefits of newer treatments" that can help such patients, said Dr. Timothy Wassenaar of the University of Wisconsin-Madison, who reported on the study at the cancer meeting.

"That's horrible," Herbst said of the unwillingness to refer such patients. He noted that newer chemotherapy treatments have extended lung cancer survival from 20 percent at one year to nearly 50 percent now.

Dr. Sandra Horning, a Stanford University cancer specialist who is president of the oncology group, said the good news is that doctors in the survey were not influenced by whether a lung cancer patient had smoked. The notion that smokers bring the disease on themselves should not interfere with treatment, she said.

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Overly aggressive treatment gives false hope

I don't believe there is any such thing as "false hope" Hope is Hope and should be treasured nurtured and cherished. When hope dies there is nothing left for the body to do but follow.

I believe it is the choice of the patient and not a doctor's. Who made them God and/or author of our destiny.

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To me, I was told that lung cancer is a treatable disease. It should no longer be viewed as a terminal illness, but rather an illness that should be treated as a chronic condition. Is this where the patients and doctors are changing the manner in which lung cancer has been aggressively treated this past decade?

I will be one of those who will say, Sock it to me! I know what it is like to be threatened. For me, every breath is a good breath until/unless I say differently.

Cindi o'h

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It is personal.. and I would venture to say that none of us know for sure what we would do in the last days, give up or keep on fighting. I do believe though that life is a precious gift and part of me would not give it up easily and at the same time I am not afraid to die. Of course, when death seems imminent, I might change my mind. I would stop chemo though if there were no more benefit. I may still keep fighting in my own mind, chemo or no chemo. I would be as mindful as I possibly could of each precious breath.

Don M

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It's easy for them to say in studies that treatment was futile during the last month or two in hindsight -- they ignore the numbers of those who would have passed without treatment and have gone on because they have no way of knowing what those numbers look like. They can't play God. Plus, if we all just had the attitude of "that's it", we would never have the newer drugs emerging that help late stage cancer --

One thing I'd like to see more of is information on quality of life for the patient as a result of treatment -- hard to find much on that one and has been hard for mom to endure unexpected QOL effects from all of this.

Linda

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Very Good point Linda..

I too would like to know who struggles with QOL after treatment. I know mine has changed as I pretty much disabled due to SOB..

Better to be SOB than SOL though..lol.

I guess it is just something that comes and you accept it (or work at trying to accept it).

Cindi o'h

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I agree with all that is said, and I will also add to the hindsight thought with this: I don't think it's always easy to know when you are in those last months. With Mom, we thought we had time for one more treatment plan at least. WE were ready to get on the bandwagon of a final trial of perifosine. Then the decline came fast and furious. Sure they know in these studies that people were treated the last two months of life--but the doctors and patients might have had no clue themselves that they were looking so closely at the end.

Then with our friend, Bob, it was the fight that kept him going. It was the idea that, "Well... Something could work!" that spurred him on. You don't mess with people's hope. You just don't do it.

What I read in this is insurance bottom-line rhetoric. It's too costly to do this and this and this. Screw that. Let's fix our health system (and I have NO IDEA how to do that), and save people's lives folks!

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Cindy, there's QOL and then there's QOL...... and I think that is the patient's choice: I agree that SOB is better than SOL, for sure! What about enduring dialysis every day or being bedridden for the rest of one's life, for example? Patients should know this stuff to be able to make informed decisions on what they want to do and how they want to spend their life. Of course, no one can say for certain what will actually happen during the course of treatments, but at least everyone knows the risks they are willing to take up front. Nothing worse as a caregiver than watching a patient suffering from catastrophic QOL effects that no one expected or were warned could happen. Mental preparedness and the spunk to live well in spite of these sorts of things is important in this journey from what I've seen so far.

Having the medical/insurance community "give up" or not be willing to pursue treatment as this thread's article suggests is an atrocity -- I just wish we could be better informed about the decisions we make in our treatment courses as well.

Linda

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"That's like a waste of the whole hospice process," which stresses preparing the patient emotionally and physically for death, Herbst said. "People have to be ready to do that."

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Personally I think as long as the person wants to be treated they should let them. Is it really crucial to be "emotionally ready" to die. If you are not sick you are not emotionally or physically ready- death just happens.

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