More is not always better

My father was diagnosed with a widespread Adenocarcinoma of Unknown Primary several years ago when he was in his mid-80s. A short course of chemotherapy had a modest impact on the cancer, but the side effects of the therapy were significant, and he decided not to continue the chemo. He enrolled in hospice, and other than a few short stays in the hospital, spent the remaining months of his life at home doing what he loved, surrounded by family. We had many discussions during that time about what therapies he should take, and what therapies he should not to take. I still miss him dearly, but am comforted to know I did what I could to assure he had the highest possible quality of life during his final months.

My advice to my father, and to my patients, is based on the knowledge that for some patients, intensive therapy with curative intent is appropriate. For others where cure is not possible, gentler therapy geared toward maintaining or improving quality of life can sometimes be a better choice.

Assuring every patient across the country gets the best possible cancer care is difficult. There is a growing demand for cancer care, treatments are increasingly complex, there are not enough well trained clinicians in the workforce, and costs of cancer care continue to rise. In addition, our current use of cancer care resources is out of balance. Some patients receive therapy that is unlikely to help, yet is costly with respect to both quality of life and actual dollars. Others do not have access to quality cancer care.

The solution requires a fundamental change in our approach to cancer care. The Institute of Medicine (IOM) recently outlined the challenges in our cancer care delivery system, and how we might respond to them, in a report titled “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.”

The new course outlined in this report will not be easy but is desperately needed. Academic cancer centers such as Holden Comprehensive Cancer Center must take the lead in charting this new course in each area of our tripartite mission of education, research and patient care.

Education
We need to improve our teaching of communication skills to the next generation of cancer clinicians so those clinicians can help patients and their families clearly understand the goals of a particular cancer therapy and what they can expect to gain (or lose) from that therapy. The decision not to use every possible cancer therapy for every patient should not be equated with giving up, rationing, or responding to “death panels.” Instead, choices should be based on what is right for each patient. With better communication and more accurate expectations, more patients would choose to do what my father did, and decide to focus on quality of life.
Research
In addition to basic and clinical cancer research, we need to explore how therapy impacts on quality of life and conduct health services research exploring more effective and efficient approaches to delivering quality cancer care to the underserved.
Patient care
In addition to providing state-of-the-art, evidence-based anti-cancer therapy, we need to provide care focused on enhancing the quality of life.

During the last few months of his life, my father repeated one of his favorite maxims—“there always will be ten leading causes of death.” I would like nothing more than to see cancer come off that top ten list, but striving for that day should not blind us to the fact that the goal of medical education, research, and care is not only to extend the lives of our patients but also to improve and enhance their quality of life. To achieve that goal, more is not always better.

One thought on “More is not always better

  1. Laurel greenbergy

    Hi George, We loved this article! That is why you are our best and favorite cancer consultant as well as favorite nephew. Hank is scheduled for an appointment with his oncologist when we return from our Mediterranean cruise. We are both feeling great now, but when the time comes, please remind us of this wonderful and sensitive article. Much love,Aunt Laurie & Uncle Hank

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