Treatment or quality of life; are they mutually exclusive?
We each have choices when it comes to managing a cancer diagnosis and exploring paths to survival.
Treatment approaches may include conventional care, an integrative oncology approach, alternative medicine, off-label drugs, or experimental drugs administered within or outside of a clinical trial, or it may consist of a combination approach.
It may mean doing none of the above. Sometimes less, or nothing, is most appropriate because there is a point where cancer ‘care’ disregards ‘quality of life’ and can hasten death.
An important framework to keep in mind:
- Each person’s cancer, and overall health and condition, is unique to him/her.
- The host environment (where disease lives) is as important to consider as the disease itself.
- We are in charge of our own bodies and minds.
- We are defined by individual circumstances, goals, and needs.
- Healing is different than ‘curing’.
- Our decisions are solely ours to make.
Until now, I have not written about when a potential treatment’s ‘end does not justify the means’.
When the end does not justify the means, even standard cancer care becomes a bad option. Because of this, there is a clear need for new patient-centered decision tools to ensure the most appropriate cancer management choices are made.
Take my friend, Eddie. Eddie was a healthy man into his mid-80s. Full of energy and vigor, he always carried a wide smile and lived life to the fullest extent. That is, until he was diagnosed with an advanced lung cancer.
After clinical appointments and discussions with Eddie’s oncologist and his family, a decision was made to begin aggressive therapy comprising surgery, followed by chemotherapy.
Though a family friend, I was not asked for direct input. I simply respected their treatment decision, observed from a distance, and offered support.
To be fair, I do not know the specifics of Eddie’s case, or whether his oncologist spelled out in clear language what his quality of life might be in getting through the various phases of treatment and recovery. Nor am I privy to the exact interventions and drug agents, and the typical response someone in his condition might expect.
But I do wonder if all those involved intentionally placed a higher priority on extending survival, at the expense of toxicity and quality of life. It’s imperative to put all these factors into the mix of consideration when deciding on such life-changing events.
Unfortunately, Eddie did not do well. He was bedridden after several months of treatment, progressive disease, and additional treatment. He was miserable, depressed, and quickly succumbed to the complications of treatment, not from the disease itself.
Effective Decision-Making for Older Cancer Patients
More than ever, older patients—in their eighties and nineties—are being treated for cancer and, in many cases, more aggressively than in the recent past.
The Comprehensive Geriatric Assessment (CGA) is the gold standard tool to guide oncologists in selecting the best cancer treatment for their older patients. It takes into account many factors, including the patient’s social support system, overall health including comorbidities (conditions in addition to cancer), and age-related changes in pharmacokinetics (how an older person absorbs drugs, based on organ function, saliva, and digestion).
Unfortunately, the CGA is relatively new and not consistently applied. There are not enough geriatric oncologist specialists. This is forcing all oncologists to care for many geriatric patients.
Some patients and their families and caregivers will insist on the most aggressive treatment approaches in hope of a potentially worthy tradeoff of shorter-term suffering in order to be around for a ‘cure’ in the longer-term.
However, in general, older folks are getting more treatment with better symptom control. Novel targeted therapies, available for those with certain types of disease, can also make treatment easier to endure.
And the issue cuts both ways. There are also cases when not enough treatment can lead to premature deaths—specifically, older persons faced with a cancer challenge. In these situations of under-treatment, those arguably strong and healthy enough to undergo treatment with ‘curative intent’ with more aggressive treatments including full-strength anticancer drugs—folks seemingly well-positioned to recover well and resume their quality of life—are not sufficiently screened.
Geriatric oncology is a real challenge, in that age can be just a number, a mere starting point of responsible decision-making. Quality decision-making requires a comprehensive process, and the family’s and practitioners’ collaboration to personalize treatment based on the overall physical, emotional, and cognitive health of each individual. It requires open communications covering the pros and cons of treatment choices, with the patient’s voice and personal needs front and center.
Cancer is strongly associated with aging. Today there are eleven-fold more cancer survivors now aged 65 or older, than those under 65. Regardless of the age at diagnosis, this group represents folks living with cancer right now. However, this does not mean every 80- or 90-something-year-old should undergo aggressive cancer therapy. In fact, there are much younger patients that are not good candidates for highly invasive and toxic regimens.
There is also a syndrome of ‘chasing disease’, where older, more frail folks continue to get routine screenings to monitor ‘quiet’ disease that may be slow growing, or to monitor for the onset of new disease.
From my perspective, it only makes sense to chase disease if the available therapies to treat such potential occurrences meet the overall objectives and condition of the patient.
Proactive monitoring is irrelevant when current methods of checking are invasive, and known treatments do not support an appropriate quality of life. On the other hand, when methods of checking are less invasive (such as scopes), and targeted therapies are suitable, then it makes sense to chase the disease through regular monitoring.
For select patients, and not just the elderly, when it comes to cancer treatment and potential outcomes, it is important to consider the quality of life in the months or years of treatment over the potential months or years of extended life.
It is critical to collect all the facts around treatment choices, potential outcomes (based on evidence), common treatment side effects and possible adverse events. These options must be weighed against the overall health of each unique patient—elderly or not—and the individual patient’s capacity to get through the recommended treatment regimen … and to fully recover over time.
Most vitally, all these factors must be reconciled in the context of overall quality of life. In some cases a palliative approach may be preferable, one solely focused on comforting the patient, allowing the individual to live their remaining time in peace, and with dignity; not to exist beholden to a clinical environment, faced with onerous interventions, pain, and suffering.