It’s the hardest thing in the world to do – or not do, as the case may be.
Someone has just been diagnosed with cancer. He or she is referred by a primary care doctor to see you. It takes about a week to get an appointment with you, so that person has plenty of time to read about the cancer online, talk to friends or family who have been treated for similar or completely unrelated cancers, and research your qualifications.
When the anointed day arrives, that person walks through the front doors of your clinic, which identify the building as a “Cancer Center” – in case the people walking through those doors needed another reminder.
Before the appointment, he or she sits in your waiting room for a potentially jarring view of cancer and its treatment in its many manifestations: people healthy and sick, hairy and bald, with clear skin and rashes, whole and disfigured. Some laughing, some neutral, and some sad; some wealthy, some destitute; some with families, some alone.
With this preamble to cancer, your patient is called back to your exam room, where he or she waits to see you, the only distractions being the Mapplethorpe photo on the wall, the Welch-Allen otoscope and ophthalmoscope hanging near the sink, and a couple of pink flyers inviting cancer patients initiating treatment to a chemotherapy education class. You walk into the room and introduce yourself.
Your patient has a low-tumor-burden lymphoma. Or an asymptomatic chronic lymphocytic leukemia with preserved blood counts. Or a lower-risk myelodysplastic syndrome with very mild anemia. Any one of these might have been detected almost by accident – by a laboratory test ordered for other reasons, or a routine physical exam that happened to detect an enlarged lymph node. You take a detailed history and perform an exquisitely probing physical examination. You make sure that the pathologic diagnosis is verified, sometimes looking at it with your own eyes.
Sure enough, the tissue specimen confirms cancer. There are abnormalities in the lab work, or on scans, or on both. The only other deviation from normal you can detect is the anxiety in your patient, as he or she awaits your recommendation. Heck, you’d be pretty anxious too if you had gone through the same experience without your cancer knowledge-base. Even with that specialized knowledge, no one appreciates being given a cancer diagnosis.
Luckily, there are a few drugs in your arsenal that you can suggest, and, luckily, many of them carry better-than-even odds that they can get your patient into a remission. Each of the drugs costs tens of thousands of dollars for a full treatment course, and some can even be used in combination with each other to improve those odds. In the blink of an eye, you can assure your patient that you can administer drugs that will make his or her cancer shrink, and alleviate that pervasive anxiety by promising action.
But should you pull the trigger?
You could play the role of Dirty Harry, the San Francisco police detective portrayed by Clint Eastwood in the 1970s. Cancer is the serial killer you’ve been hunting.
“I know what you’re thinking,” you say when you confront the indolent lymphoma. “Will he use six chemotherapeutics, or only five? Well, to tell you the truth, in all of this diagnosis and prognostication, I’ve kinda lost track myself. But being as this is a monoclonal antibody and a checkpoint inhibitor – the most powerful and expensive chemotherapeutics in the world – that would blow your quickly dividing cells clean up, you’ve got to ask yourself a question: ‘Do I feel lucky?’ Well, do ya?”
You justify this approach by telling yourself that you are making your patient feel better by “doing something.” That, surely, your patient will derive benefit by knowing that his or her cancer is shrinking.
Maybe that is true.
But remember, your patient was asymptomatic when he or she first walked through the doors of your cancer center. The therapies you can offer have never been shown to enable people to live longer. And if your patient has no symptoms due to cancer, these therapies, by definition, will not improve his or her quality of life. In fact, in the absence of pre-existing symptoms, the only thing these therapies have the chance of contributing are side effects to the drugs themselves.
So, you can go ahead and treat the cancer. That’s the easy answer. It will definitely make you feel better.
Or, you can spend time educating your patient about the disease, and adjusting his or her expectations. It does take a greater investment of your time, and active surveillance requires even more of an investment in emotional energy on the part of both you and your patient.
But in the end, it’s the right path to take. It’s better for your patient, and it’s better for society. You’ve got to ask yourself a question: “Do I have the strength to not treat a non-lethal cancer?”
Well, do ya?
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.
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