Appropriate Level of Aggressiveness in Hem/Onc?

[thisampgoestoeleven]

I have recently been wondering whether I went into the right field, because I often don't feel comfortable subjecting patients to fourth or fifth line therapy when I feel they would be better served with hospice. I am training in a large cancer center where 90% of my teachers push patients to the brink of death, with many to die with chemotherapy in the last 2 weeks of life.

Is this an academics thing, or all of oncology thing? Maybe I should do benign heme.

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[CorneliusVanDerBroke]

I think that, regardless of what you decide to do with your career, you should be your patients' advocate. If they understand all the options on the table, including palliative care and hospice, and choose to pursue 5th line treatment, that's acceptable. If the only option they're being presented with is 5th line treatment that, in my opinion, is ethically unacceptable.

I would encourage you to use your voice and speak up, be their doctor. Your program chose you to be a fellow for a reason, draw from your experiences and try to help patients make the best choice for them, even if it is a choice that you, or the attending disagree with. Sometimes attendings can get tunnel vision about new drugs, trials, etc and lose sight of the big picture. Help people make informed decisions with all the information and you'll be a better doctor and oncologist as a result.

 

[gutonc]

This is a general oncology thing, but it's not universal. I saw it in residency, and I see it now in my community based practice and those of my friends. One thing that seems kind of common is that it's the older oncologists who seem to be pushing Nth line treatment, while many/most (but certainly not all) of the more recent grads tend to focus on QOL over squeezing another 3 weeks out of another line of therapy. I was fortunate to have a couple of mentors in fellowship (one GI, one Breast) who had similar approaches to treatment, and I think it has served me, and more importantly, my patients, well.

Here's the most important thing though...in a few years, you get to be the one that decides how to approach this issue. Learn what you need to learn now from everyone you can, practice how you think is best once you're on your own.

 

[thisampgoestoeleven]

Thanks. After some thought I have realized that:

1) Patients who are highly fit, motivated, or crazy, can go to the ivory tower (i.e., not where I plan to be in a few years, anyway) for their umpteenth line of treatment.

2) After two or three lines of established therapy, really it should be clinical trial, since most 3rd line chemotherapy regimens (outside of mal heme, prostate) have single digit response rates. That said, many of the patients in the immunotherapy and CAR-T trials who achieved durable responses were heavily pretreated, and written off for dead.. so there is something to be said about getting such patients onto trials. (Though to be fair, most phase 1 trials have crappy response rates, as well.)

3) Palliative care / hospice is underused, and even after the Temel study I find that even in NSCLC arena where pall care / hospice is underutilized.

4) Malignant heme is just as bad. The transplanters will take a patient to the grave trying to clean up a relapsed leukemia or Gr 4 GVHD. So not trying to pick on the solid tumor folks, here.

5) Guiding patients to know when to keep fighting vs. when to focus on comfort is one of the most agonizing parts of the field. There's always an oncologist who would be willing to treat further.

 

[gutonc]

Thanks. After some thought I have realized that:
5) Guiding patients to know when to keep fighting vs. when to focus on comfort is one of the most agonizing parts of the field. There's always an oncologist who would be willing to treat further.

This is actually my favorite part of the job. I tell all of my "incurable" patients up front that my goal is to help them have a good life as long as I can, and then to have a good death when that's no longer possible. It's hard, and a hell of a way to start a patient-doctor relationship.

And I definitely get fired by some patients who don't think I'm "fighting hard enough" for them. I'm OK with that. I'm not the right physician for them. I know plenty of docs who can figure out how to get one last cycle in at the crematorium.

 

[deleted547339]

If you have someone on their 7th line of treatment and haven’t talked about what the end of their life looks like, you’re a bad doctor and probably a bad person.

I’m an icu doc. I just had to tell a young guy and his wife that he was going to die (probably today). His oncologist had never discussed this with him. They weren’t sure they believed me because they have had a doctor for a couple years - of course if he was going to die, they would have told him. I’m just some guy he just met - why should he believe me.

His death is predictable and the opportunity to pass on his terms was stolen from him by an overzealous oncologist. Don’t be that guy or gal.

 

[whoknows2012]

If you have someone on their 7th line of treatment and haven’t talked about what the end of their life looks like, you’re a bad doctor and probably a bad person.

I’m an icu doc. I just had to tell a young guy and his wife that he was going to die (probably today). His oncologist had never discussed this with him. They weren’t sure they believed me because they have had a doctor for a couple years - of course if he was going to die, they would have told him. I’m just some guy he just met - why should he believe me.

His death is predictable and the opportunity to pass on his terms was stolen from him by an overzealous oncologist. Don’t be that guy or gal.

The one thing I’ll say to play devils advocate is I’ve had several patients in whom I’ve done the following;

1) told them their stage IV cancer is incurable and terminal
2) told them that treatment is focused on palliation and quality of life
3) when there is progression of disease I remind them of #’s 1 and 2 and reassessing their Interest for further treatment reminding them as well that with each additional line comes less chance of benefit and more likelihood of toxicity

All the above notwithstanding, I still routinely get calls from pall care and the primary team confused why I haven’t discussed with the patient the prognosis. Of course I have. A lot of this can be denial or difficulty in accepting the diagnosis. So while I know for sure there are oncologists that are not up front with prognosis or end of life discussions this is absolutely not universal

 

[deleted547339]

The one thing I’ll say to play devils advocate is I’ve had several patients in whom I’ve done the following;

1) told them their stage IV cancer is incurable and terminal
2) told them that treatment is focused on palliation and quality of life
3) when there is progression of disease I remind them of #’s 1 and 2 and reassessing their Interest for further treatment reminding them as well that with each additional line comes less chance of benefit and more likelihood of toxicity

All the above notwithstanding, I still routinely get calls from pall care and the primary team confused why I haven’t discussed with the patient the prognosis. Of course I have. A lot of this can be denial or difficulty in accepting the diagnosis. So while I know for sure there are oncologists that are not up front with prognosis or end of life discussions this is absolutely not universal

You’re not the doc I’m talking about. I’ve had plenty of patients with awful cancer in denial. We are all aware of that. I’m talking oncologists (who seem to usually be trialists) who have multiple patients dying in the icu every month and don’t get that death doesn’t have to involve lines, tubes, machines, pain and being unconscious and unable to interact with loved ones.
Also, offering treatment and making a patient DNR aren’t mutually exclusive but often get conflated.

 

[whatup2016]

Just want to say this thread is very reassuring and underlines the fact that a lot of new/younger oncologists truly prioritize being transparent with patients, discussing goals, and providing the best care (knowing that palliative care and hospice are essential to that).

To the OP, it’s great that you’re questioning your attendings treatment plans. As others have said, learn what you can, and take comfort in knowing when you’re the primary oncologist, you will be able to provide better care for your patients.

 

[gutonc]

This thread reminded me of a case I've been struggling with and wanting to write about for awhile now. I just did. It's in the Practicing Physicians forum. Still pisses me off.

 

[deleted547339]

This thread reminded me of a case I've been struggling with and wanting to write about for awhile now. I just did. It's in the Practicing Physicians forum. Still pisses me off.

can I get permission?

 

[whoknows2012]

can I get permission?

me too? @gutonc

 

[NITRAS]

Make a thread in the help desk. They will get back to you.

 

[gutonc]

Make a thread in the help desk. They will get back to you.

What s/he said.