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You are here: Home: BCU 4|2002: Editor's Note
Editor's Note
"Doctor, what would you do if you were in this situation?"
| Do you think most oncologists recommend treatments to patients with metastatic breast cancer that they would want to have in the same situation?
"At some level I hope they do, but on another level, I hope they don’t. Let me explain: When we choose between similar treatments with different side effects, what we should recommend to our patients is not necessarily what we would choose for ourselves, but the treatment which — after talking to that patient — fits best with that patient’s preferences. Often the treatment recommendation may not be the one we would choose for ourselves. For example, I might be terrified of neurotoxicity, but my patient may not. Maybe, playing the piano is everything to me. But, more often than not, we do recommend the treatment that we would choose for ourselves, and patients go along with it since there is not that much variability in people’s preferences."
— Eric P Winer, MD |
Nothing is more fascinating than "picking the brain" of a thoughtful and experienced research leader like Eric Winer. Reflecting on his comments in the enclosed audio program, I realize that one of the greatest challenges that we face in oncology is gaining enough emotional proximity to the patient to provide empathetic care, while simultaneously distancing ourselves adequately to allow for rational management of the case.
To assist medical oncologists in negotiating the slender divide separating them from their patients in choosing less than perfect therapies, the Breast Cancer Update series queries research leaders about how they integrate emerging trial data into clinical decision-making. My role, in interviewing these investigators, is to pose tough and sometimes unanswerable questions about patient care in order to arrive at clinical examples that physicians can utilize in practice. But these theoretical conversations often do not address the very real emotions felt by cancer patients and loved ones.
| “I was so afraid — and I’m the type of person who usually has an answer for everything and can control everything — but all of a sudden, I felt out of control. I would have loved to be able to say, ‘Well, yes, doctor. Let’s sit down and discuss the plan. Let’s do this. Let’s do that.’ I felt totally lost, and the only thing I could think was to ask him, "If this were your wife, what would you do? What would you recommend?"
— 44-year-old woman with breast cancer reflecting on the initial diagnosis.
(Miami Breast Cancer Conference patient video presentation) |
The question this woman asks is so poignant that it compels us to wonder: What if this truly was the case? What if you or your loved one was suddenly in a similar situation? What choices would you make? What factors would influence your decision? Here is an interesting exercise in that regard:
| Imagine that you were in the following situation:
Three years ago, you were diagnosed with a localized cancer that was excised. Based on a long-term predicted risk to develop metastases of about 50%, you were treated for six months with adjuvant combination chemotherapy that resulted in alopecia, fatigue and moderate gastrointestinal toxicity. Your hair grew back, and you felt relatively well for over one year. However, recently you have experienced increased difficulties in breathing, which limit you from performing even mild physical activities. You notice a red lesion on your stomach. Your oncologist recommends that you receive a chest X-ray, which reveals parenchymal nodules. Biopsy of the skin lesion confirms a recurrence of your primary cancer. Your treating physician reviews the following options for your consideration (presented here in brief), noting that therapy is very unlikely to eradicate this cancer:
- Agent A, administered intravenously, which is associated with alopecia, myelosuppression and neurotoxicity.
- Agent B, an oral agent, which does not cause the toxicities associate with agent A. However, it may cause pain and redness in the hands and feet that can usually be avoided with dose reductions.
- A combination chemotherapy regimen consisting of two agents (A and B) that seems to result in a greater likelihood of tumor response than either alone and a modest (a few months) increase in overall survival.
- Agent C, which is administered intravenously and is associated with alopecia, myelosuppression and neurotoxicity but less overall toxicity than agent A.
There is the general impression that agent A might be more effective than B or C but with more toxicity. Overall, the combination of agents A and B will provide the greatest chance of a tumor response but also the greatest likelihood of toxicity. Agent B is probably the least toxic of these choices, and many research leaders believe that in the long term, it may not make much, or any, difference which of these options is used initially.
Which of these treatment approaches would be most compelling to you in this situation? |
In January 2002, as part of a special education initiative associated with the Miami Breast Cancer Conference, our team conducted a national telephone survey of 200 randomly selected oncologists and surgeons. These physicians were presented with dozens of breast cancer clinical scenarios. The results, along with many of the interactive keypad case questions presented during the Miami meeting, are summarized in a special report enclosed with this issue of Breast Cancer Update. A more comprehensive compilation of these data is on BreastCancerUpdate.com.
The following case scenario from interactive keypad polling of attendees at the Miami Breast Cancer Conference is very similar to the clinical situation described above:
Case: A very ill 43-year-old woman presents with lymphangitic lung metastases. She
had an ER-negative, HER2-negative breast cancer two years ago and received AC-->T
adjuvant chemotherapy. |
| The most common recommendations by oncologists for this case were: |
| Capecitabine/docetaxel |
55% |
| Anthracycline/taxane |
14% |
| Capecitabine |
14% |
| Vinorelbine |
7% |
| Taxane |
5% |
| Other |
4% |
|
| |
In analyzing the patterns of physicians’ responses to the theoretical case scenarios, it is fascinating to isolate the effects of specific variables on treatment trends. Age is one such example. At arbitrary cut points, a minimal shift in age sometimes leads to significantly different treatment recommendations. For example, a theoretical case of a 76-year-old woman may lead to much more aggressive treatment recommendations than the case of a 79- or 80-year-old woman. In practice, of course, one assesses the physiologic age in conjunction with the patient’s attitude leading to a gestalt that guides patient management.
Seasoned oncologists not only rely on clinical research and research leader opinion, but also on their own clinical experiences with other patients in similar situations. When asked how he taught fellows in training the “art of oncology,” Dr Winer paused and replied, “by example.”
The data presented in our special report suggests considerable variation in practice patterns. This is not an entirely surprising phenomenon. Experienced oncologists rely on a multitude of factors to shape their decision algorithm. Clinical research and the opinions of leading investigators as well as our own practice experiences dealing with other patients in similar situations all play prominent roles. But what makes the art of oncology so challenging is that there is no “one size fits all” treatment. Each patient is a unique individual whose needs, desires and concerns must be given equal emphasis in the complex equation of treatment selection.
Speaking of size and addressing needs, you will note that one year after relaunching the Breast Cancer Update series with an enhanced CD-containing version, we have enlarged the print supplement, and tinkered with our graphic presentation. Your feedback on these changes and suggestions for future speakers and topics are most welcome.
— Neil Love, MD
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