I once had a patient who left me a negative review because I told him his asymptomatic metastasis didn’t need me to radiate it despite my lengthy attempt to explain my rationale
I’d add failure to offer prognosis and failure to provide in a comprehensible, quantitative manner. Most people don’t spend their lives studying cancer survival rates by type, stage, and treatment effectiveness. They can be clueless about their situation. Research shows patients want and value prognostic information. The reasons why doctors give for not providing are understandable but not excusable in the vast majority of cases.
The decision to treat metastatic disease is incredibly nuanced, and this is exactly where broad generalizations can get you into trouble.
There is also a big difference between proving a mortality benefit and preventing morbidity.
I do not need a randomized trial to tell me that allowing a patient with metastatic breast cancer to progress until they develop painful bone metastases is not a good strategy. Nor do I need one to tell me that waiting for a patient with melanoma to develop neurologic complications from brain metastases is somehow preferable simply because they felt well a few months earlier.
Sometimes observation is absolutely appropriate. But the timing of treatment depends on disease biology, tempo, sites of metastases, available therapy, expected time to response, and the consequences of progression. Good oncologists make these calls everyday.
And with immunotherapy in particular, which can take months to work, waiting until someone is already symptomatic or clinically deteriorating can mean you have missed an important therapeutic window, sometimes for cure.
My dad was diagnosed with stage 4 esophageal cancer some years ago. He lived 6 months after diagnosis. He endured radiation and chemo spending more time in the hospital secondary to fall out from the chemo than in his own home. He had 3 PET scans in those 6 months. I asked myself WHY then and even more so after this discussion. Thank you Dr.Prasad for this brutally honest and much needed set of recommendations. Cancer treatment has become an industry.
In some cancers, such as with the mix of subtypes of kidney cancer, the change of standard of care, per the stage of the various cancers, and how the patient responded or failed to do, give important help to the treating doctor. But patients usually want the damn thing out, and can only think of cancer as ONE thing, and cannot truly understand the dramatic changes which may have occurred since a family member died/suffered 15 years ago, or similar. We patients desperately need good education about cancers, as do the doctors who attempt to treat a wide range of cancers without adequate training. Not easy!
I'm particularly interested in how the quote at the end of item 2:
"We do have randomized data in some tumors that leaping to treat biological markers just adds more chemotherapy, more side effects, more cost, but no more life."
applies to kappa light chains in the context of multiple myeloma. My mom has started a new drug with this biomarker as the triggering mechanism. She was and still is totally symptom free. She suffered an aneurysm and then a subdural hematoma last year and has had a few ongoing, but still relatively minor cognitive issues. They seem to be getting worse with the new treatment.
MDs don't push me around because of my personality. I have had five cancers in 25 years and I had the best MDs and the best hospitals-- I live in NYC. And I was lucky. None of them was painful or even uncomfortable. Four of them involved surgery. One--stage 4 Lymphoma-- had chemo. I had no side effects at all. In fact, I never felt better because of the steroids. Also with the chemo I think the "cocktail" was copasetic with my chemistry.
Are there any good updates studies on hormone blocker use for ER/PR+ breast cancer? Before meeting my Oncologist next week I want to be equipped with good information.
Just found 5mm of DCIS seen as micro-calcifications on mammogram. Lumpectomy done in July. Stage zero. Grade 1. No nodes. Nothing more found on bilateral chest/breast MRI. Referred to radiation Onc and medical Onc. Will see both next week. I’ve had a lot of radiation over the past 24 years for 2 previous breast cancers.
I had my first bout with ER/PR+ HER2- invasive ductal breast cancer in 2002 at the age of 45. Found on self-exam, never seen on mammogram but seen on ultrasound. 1.6cm. Stage 1. No nodal involvement. Had 2 rounds of chemo (no Oncotype available at that time). 33 radiation treatments and 4.5 years of Tamoxifen.
16 years later, discovered on mammogram, 0.8mm tumor in the other breast, same cancer type. No chemo needed (based on Oncotype) but 16 radiation txs and 2 years of Anastrozole. (I hate how no estrogen affects me for several quality of life reasons and quit early).
This catalogue of medical malpractice (and that is what it is) occurs in other specialties. As a recently retired cardiologist I can confirm that the overuse of coronary stents, in spite of is massive, and this is confirmed by overwhelming evidence. No-one knows but in Australia may well be up to 50% of stents confer no benefit over optimal medical treatment. Might be even higher in USA. Similarly ablation for atrial fibrillation is almost certainly excessive. The financial incentive seems to be irresistible
I once had a patient who left me a negative review because I told him his asymptomatic metastasis didn’t need me to radiate it despite my lengthy attempt to explain my rationale
I’d add failure to offer prognosis and failure to provide in a comprehensible, quantitative manner. Most people don’t spend their lives studying cancer survival rates by type, stage, and treatment effectiveness. They can be clueless about their situation. Research shows patients want and value prognostic information. The reasons why doctors give for not providing are understandable but not excusable in the vast majority of cases.
Counterpoint:
The decision to treat metastatic disease is incredibly nuanced, and this is exactly where broad generalizations can get you into trouble.
There is also a big difference between proving a mortality benefit and preventing morbidity.
I do not need a randomized trial to tell me that allowing a patient with metastatic breast cancer to progress until they develop painful bone metastases is not a good strategy. Nor do I need one to tell me that waiting for a patient with melanoma to develop neurologic complications from brain metastases is somehow preferable simply because they felt well a few months earlier.
Sometimes observation is absolutely appropriate. But the timing of treatment depends on disease biology, tempo, sites of metastases, available therapy, expected time to response, and the consequences of progression. Good oncologists make these calls everyday.
And with immunotherapy in particular, which can take months to work, waiting until someone is already symptomatic or clinically deteriorating can mean you have missed an important therapeutic window, sometimes for cure.
Very helpful!! Thank you again Dr Prasad for helping patients understand their choices
FANTASTIC!
Music to my ears...
My dad was diagnosed with stage 4 esophageal cancer some years ago. He lived 6 months after diagnosis. He endured radiation and chemo spending more time in the hospital secondary to fall out from the chemo than in his own home. He had 3 PET scans in those 6 months. I asked myself WHY then and even more so after this discussion. Thank you Dr.Prasad for this brutally honest and much needed set of recommendations. Cancer treatment has become an industry.
In some cancers, such as with the mix of subtypes of kidney cancer, the change of standard of care, per the stage of the various cancers, and how the patient responded or failed to do, give important help to the treating doctor. But patients usually want the damn thing out, and can only think of cancer as ONE thing, and cannot truly understand the dramatic changes which may have occurred since a family member died/suffered 15 years ago, or similar. We patients desperately need good education about cancers, as do the doctors who attempt to treat a wide range of cancers without adequate training. Not easy!
Sorry for your loss. Hope they were up front regarding prognosis. That does seem like too many pet scans.
I'm particularly interested in how the quote at the end of item 2:
"We do have randomized data in some tumors that leaping to treat biological markers just adds more chemotherapy, more side effects, more cost, but no more life."
applies to kappa light chains in the context of multiple myeloma. My mom has started a new drug with this biomarker as the triggering mechanism. She was and still is totally symptom free. She suffered an aneurysm and then a subdural hematoma last year and has had a few ongoing, but still relatively minor cognitive issues. They seem to be getting worse with the new treatment.
the problem is changing doctors is all but impossible unless you are extremely rich.....or knowledgeable...
MDs don't push me around because of my personality. I have had five cancers in 25 years and I had the best MDs and the best hospitals-- I live in NYC. And I was lucky. None of them was painful or even uncomfortable. Four of them involved surgery. One--stage 4 Lymphoma-- had chemo. I had no side effects at all. In fact, I never felt better because of the steroids. Also with the chemo I think the "cocktail" was copasetic with my chemistry.
Are there any good updates studies on hormone blocker use for ER/PR+ breast cancer? Before meeting my Oncologist next week I want to be equipped with good information.
Just found 5mm of DCIS seen as micro-calcifications on mammogram. Lumpectomy done in July. Stage zero. Grade 1. No nodes. Nothing more found on bilateral chest/breast MRI. Referred to radiation Onc and medical Onc. Will see both next week. I’ve had a lot of radiation over the past 24 years for 2 previous breast cancers.
I had my first bout with ER/PR+ HER2- invasive ductal breast cancer in 2002 at the age of 45. Found on self-exam, never seen on mammogram but seen on ultrasound. 1.6cm. Stage 1. No nodal involvement. Had 2 rounds of chemo (no Oncotype available at that time). 33 radiation treatments and 4.5 years of Tamoxifen.
16 years later, discovered on mammogram, 0.8mm tumor in the other breast, same cancer type. No chemo needed (based on Oncotype) but 16 radiation txs and 2 years of Anastrozole. (I hate how no estrogen affects me for several quality of life reasons and quit early).
Thank you.
This catalogue of medical malpractice (and that is what it is) occurs in other specialties. As a recently retired cardiologist I can confirm that the overuse of coronary stents, in spite of is massive, and this is confirmed by overwhelming evidence. No-one knows but in Australia may well be up to 50% of stents confer no benefit over optimal medical treatment. Might be even higher in USA. Similarly ablation for atrial fibrillation is almost certainly excessive. The financial incentive seems to be irresistible
It’s so much higher in the us - we stent dying cancer pts.
Excellent advice. BUT exactly how many oncologists actually follow this advice? I suspect very few.