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End of life chemotherapy: unnecessary, costly, and decreases quality of life

Discussion in 'Hematology / Oncology' started by Dermalicious123, Aug 13, 2015.

  1. Dermalicious123

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    http://oncology.jamanetwork.com/article.aspx?articleid=2398177

    http://www.nytimes.com/2015/07/24/health/chemotherapy-may-worsen-end-of-life-quality-study-finds.html

    Could we have a discussion about this new research? Is the landscape of cancer care changing? I get infuriated when oncologists push for chemotherapy when the patient has no chance of a full recovery. Even if that patient gets to live a couple of months longer, the side effects of chemo can be very harsh and contribute to a poor quality of life. Then, they end up dying in the hospital...

    In my opinion, traditional chemotherapies should not be used anymore--we need to do away with old paradigms of care and focus on using immunologically based and targeted cancer treatments (using the body's immune system to target cancer cells, for example chimeric antigen receptor T cells).

    I just get angry...would any doctor want to spend his or her last few months on chemotherapy? The entire system of cancer care must change...we're doing our patients a huge disservice and taking advantage of their lack of knowledge. Palliative care and hospice must be prioritized.
     
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  3. gutonc

    gutonc No Meat, No Treat
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    Lots of us are already having this discussion. I have discussed it with half a dozen patients since the paper came out.

    But, in general, SDN frowns on people coming into a particular specialty forum out of nowhere and shi**ing all over them like you did here. So I doubt you're going to get the kind of discussion you claim that you want (which you clearly don't actually want since you seem to have made up your mind already about what oncologists should do, without any apparent knowledge of the specialty).
     
  4. bashwell

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    SJWs hating on oncologists now? No thanks, I think I'll pass.
     
  5. Dermalicious123

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    In my experience, oncologists are honestly truly clueless about effective cancer care as anyone else..cancer treatment is literally the definition of algorithmic/cookbook medicine.
    cancer care is such a complete mess around the world which is why although I initially was interested in oncology, I realized as a medical student what a gigantic ****storm it is.
     
  6. bashwell

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    Since you've already firmly made up your mind about oncologists and oncology, what's there to "discuss" with you? It sounds more like you're trying to start a dispute. Sowing discord. Trolling.
     
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  7. Dermalicious123

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    I guess I'd like to see some serious changes in the field of oncology and how cancer patients are treated. I'm sorry if I come across as overly harsh but I think seeing the way cancer patients are treated today, that criticism is 100% merited. I've also had many family members with cancer receive some questionable treatments....It's only through criticism and identifying the issues with cancer care today that we can give our patients the best cancer treatments that emphasizes quality of life than length of life. In any hospital, there are so many patients that have such a miserable quality of life that we are artificially keeping alive when the humane and ethical thing to do would to let them die peacefully without intervention.
     
  8. Crayola227

    Crayola227 The Oncoming Storm
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    Public health considerations such as cost, etc etc aside

    As long as patients are competent, and are given informed consent regarding realistic outcomes, I'm going to leave it up to them to decide what discomfort they are willing to endure for the chance to prolong THEIR life.

    Some people would take 3 months puking just to know they are doing all they can just to get one more day over 3 months better QOL knowing they are forgoing any chance chemo will help

    I've had patients on ventilators, awake and competent, unable to move, atrocious QOL, and they and their families wanted to do everything for one more day (and what we were doing was not a question of futility or great expense)

    other docs thought "atrocious QOL, just let them die"

    I think that's beyond f*cked. I'd be a quadriplegic with rotting bed sores on chemo sick and unable to speak if I could sit with my loved ones and watch another Supernatural episode with them

    Other docs wouldn't be willing to accept that QOL. Different strokes for different folks.

    I had an elderly patient with fairly good QOL, got pneumonia, needed a few days on BIPAP while we cleared it up, every reason to think a few days and they'd be back to baseline (which was good), and they said, "no thank you ma'am" and chose to die surrounded by friends and family

    I thought it was a damn shame, it's not what I would have done for myself

    I want you to realize your job is to help your patients make informed decisions by giving them as complete and accurate info as you can, steward resources as best you can, but ultimately try to realize what is right for THEM and THEIR values
     
    #7 Crayola227, Aug 13, 2015
    Last edited: Aug 13, 2015
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  9. bashwell

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    I think you're painting with a tremendously broad brush here. There are so many variables to consider in all this.

    Do you have any med relevant experience working in oncology yet (e.g. have you done a rotation in oncology)? One reason I ask this is because you're placing all the blame on oncologists and oncology as a field but in my experience it seems the people who most often push hardest for more chemo is family members of the cancer patient who don't want to let their loved ones go. If you're going to blame people, then why not blame the patient's family members as well?

    Why not blame the general public's expectations about what oncologists can and cannot do, and what oncologists should and should not do?

    While we're at it, why not blame insurance companies for refusing to reimburse physicians unless treatment is followed exactly as they deem best?

    And so on.

    Why only blame oncologists and oncology?
     
    #8 bashwell, Aug 13, 2015
    Last edited: Aug 13, 2015
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  10. DrMikeScott

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    Why is this thread still going? This person is clearly trolling with inflammatory remarks. Intelligent conversation doesn't include "all ____ subspecialty doctors are horrible." Most of us go into this field (medicine, and in this particular forum, oncology) because we very much care about our patients and their treatment.

    I feel like regardless of what any of you say, his/her opinion will not change and doesn't really sound like they're aiming to change it. It sounds like the poster had a bad experience with a family member and is taking it out on here.
     
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  11. Dermalicious123

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    Your response proves my point exactly.

    What I'm arguing is that cancer care needs a paradigm shift. If you're denying that cancer treatment and care have several issues and problems that need to be dealt with, then there's no point in having a discussion with you. Read the research article!

    In response to other posters, yes, I wrote this post after a rotation in hem/onc (honestly appalled by what I saw).
    The blame is shared among oncologists, among this culture of having a "battle" with cancer with "winners" and "losers" (ridiculous), cancer charities and organizations that push for unrealistic outcomes and drive patients' hopes up, this culture of "letting family down" if I refuse treatment...the paradigms of cancer care (let's try this drug and see if it works, oh it doesn't let's try this one and so on and so forth).

    Honest to god, I've seen a patient go through 3 unsuccessful bone marrow transplants and go through so much suffering because of this stupid "culture" of "not giving up" that surrounds cancer. Death is not a matter of winning or losing; it's inevitable.

    If the oncologist actually had a discussion with the patient and the family and explained "it's okay to stop treatment, it's okay to refuse treatment, it's okay to spend the time you have left doing what you enjoy with the people that you love." If this was more often the case, patients would be more in control of their medical decisions. Oncologists need to be realistic, stop offering false hope, stop offering further treatments, stop perpetuating this horrid culture that has messed up cancer care. And let's talk about clinical trials. The clinical reports that I see on the front page of NEJM, they literally compare drug A to drug A+B, with the combination providing a few months of life with usually more side effects and decreased quality of life. Clinical trials like these are one step forward, two steps back; they literally do nothing to elucidate cancer mechanisms at all....just why are we wasting money on this kind of research.
     
  12. Crayola227

    Crayola227 The Oncoming Storm
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    I see you applying your own values here
    I would take drug A+B for a few extra months with SE and decreased QOL
    Because for me increased QOL is being alive, (the major SE of death is zero QOL) but it's up to each individual what trade off they want
    I would undergo 3 unsuccessful bone marrow transplants but not for a "stupid" culture but because the value I place on doing everything to live
    Dr. Cox said something on Scrubs about how fighting death is actual what our f*ing jobs are
    Not that that should be done at any cost, but boiled down to a nutshell

    The oncologist should tell them it's OK to stop treatment, but you're editorializing here with "time left doing what you enjoy with the people you love"

    I read that paper, and basically there's a hindsight view coming from the family
    it's food for thought, certainly

    I will just agree with you that we need to educate patients fully, with more time and explanation and realism
    And create a culture where pursuing treatment and NOT is equally OK and up to the patient

    A lot of docs go through this phase where you see all the ways we are actually doing what my signature suggests
    keeping people alive to the point of torture

    The only way to reconcile this is to honestly ask yourself are we working in service of what the patient themselves would want
    if everyone involved truly understood risk/benefit
    doesn't happen that way as much as it should
     
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  13. RustBeltOnc

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    A few points (at this risk of "feeding a troll"):
    1. "rotation" -- done at an academic center. You weren't in my community-based clinic during the many days when I recommend hospice to multiple patients.
    2. "discussion ... it's okay to stop treatment" -- See above. I have this discussion every day, sometimes all day.
    3. "need to be realistic" -- Most of us are. If there isn't good data to do intervention X, and the patient's time is limited, we tell the patient and have informed discussion.
    4. Trials --- very important. Especially immunotherapy for melanoma, and likely Hodgkin's
    5. Please google "Oncology Care Model".
     
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  14. Dermalicious123

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    Thanks for your insight. Maybe you're right about my experience at an academic hospital. It seems like oncologists treat patients almost like experiments rather than humans at big, academic cancer centers...

    In the end, it comes down to information. Are patients informed enough at the onset of their cancer treatment? What about patients who are minorities or are immigrants or have language barriers? It's extremely complex and difficult to have cancer treatment discussions with those patients--almost seems like they are being taken advantage of by the medical system and it is heartwrenching to watch.
     
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  15. Dermalicious123

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    Thank you for your insight. I guess now that I am in medical school (the "other" side), I realize there are a lot of issues in the way medicine is taught and practiced today. I try to be as empathetic as I can, placing myself in the shoes of my patients. But yes, everyone's different and everyone has their value systems. I just hope that patients are making decisions such as continuing end of care chemo with the right information and expectations.
     
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  16. bashwell

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    1) Sorry but you've just moved the goalposts. You originally placed all the blame on oncologists and oncology. Now you're saying the blame is "shared" among oncologists.

    When someone moves the goalposts, they're implicitly conceding their original claim was mistaken, but without explicitly conceding their original claim was mistaken. This then suggests they're not discussing in good faith.

    It's stuff like this that makes people think you're trolling.

    2) What you originally alleged (i.e. placing all the blame on oncologists and oncology) is quite different than saying some or many oncologists may be to blame. No one doubts there are some or many bad or mistaken oncologists out there, just as there are some or many bad or mistaken [insert any other group of physicians or many other vocations] out there.
     
    #15 bashwell, Aug 14, 2015
    Last edited: Aug 14, 2015
  17. bashwell

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    To be fair, this could be what happens at your hospital. It might not be true in general. Or in the community.
    No doubt it's complex and difficult. But there's help as well (e.g. palliative care physicians, translators or interpreters).

    Since you've noticed this problem where you are, why not do what you can to change (as you say) "the culture" of oncology where you are? As Gandhi said, "be the change you want to see in the world." There have been many medical students who have done remarkable things as medical students. Why not you as well?
     
  18. Crayola227

    Crayola227 The Oncoming Storm
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    To be fair, I remember being told as a med student that I would never again have as much luxury of time to sit and be with my patients.
    Word.
    I remember thinking my role as a med student was mostly bull**** and sitting around, and as an intern I still think that's true, but it's true no one is in a better position than you to take the time and be sure your patients actually know what the **** is going on
     
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  19. doctorplatelet

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    If i get cancer and i can tolerate it. I will go on a clinical trial and receive chemotherapy if that can benefit someone else.
    Nothing wrong in doing it.

    I refuse to believe that any oncologist is not going to give a patient the data out there on survival when someone asks.
    So most patients are aware of prognosis when they make a decision TOGETHER with their oncologist.

    Newer drugs and targeted agents are far less toxic, and have in a subset of patients excellent responses,
    A. this is will improve quality of life for patients
    B. We would never have had them unless some desperate/motivated patient participated in a clinical trial.

    Dont Judge your Doctor. Dont judge your patient. Be balanced.

    Thanks.
     
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  20. TheTao

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    Substitute the word "doctor" with your Mother/Father/Sister/Brother/Spouse/Child.

    Then get back to us.
     

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