By: Robert M. Wachter
I FREQUENTLY care for patients with advanced cancer. A majority have already tried some combination of surgery, chemotherapy and radiation. Many have landed back in the hospital because the cancer has returned or spread widely and left them in intractable pain or struggling to breathe.
The hospital stay is often a time when patients decide to stop aggressively fighting their cancer, and instead to focus on palliative care and achieving a measure of comfort and grace at the end of life. The moment of transition can be subtle. It’s sometimes signaled by a sweet look from a husband to a wife, a gentle touch of the patient’s hand by an adult child, or two simple words: “It’s time.”
Over the past 20 years, evidence has demonstrated that palliative care decreases pain, improves comfort and even, in some cases, prolongs life a few months. In my experience, conversations about turning to it often begin with patients recognizing that curing their cancer is impossible. Patients sometimes ask for my opinion on this. While the conversation is often heartbreaking, it has rarely been a hard call.
But now it is. And that has thrown a wrench into the way we treat patients with advanced cancer.
The reason is a new generation of cancer treatments that have become available in recent years. Some, called immunotherapy, harness the patient’s own immune system to battle a tumor. Others, known as targeted therapies, block certain molecules that cancers depend on to grow and spread. The medical literature — usually circumspect when it comes to cancer, in light of many overhyped treatments in the past — now fairly gushes with terms like “revolutionary” and “cure.” In this case, the hype feels mostly justified.
Much has been written about the promise of these treatments, as well as their staggering costs — many cost several hundred thousand dollars a year. But what strikes me most about them is that by blurring the line between cure and comfort — and between hope and hopelessness — they have disrupted the fragile equilibrium that we doctors have long taken for granted.
I recently cared for a woman in her 80s, clearly dying of lung cancer. Or so I thought. “But what about immunotherapy?” her family wondered. When I reluctantly asked our oncologist about this, he didn’t scoff. “It could work,” he said quietly, as if not quite believing what he was saying.
Oncologists are seeing patients whose cases they once would have pronounced hopeless experience Lazarus-like responses to these new therapies. One of my hospital’s specialists in multiple myeloma, a bone marrow cancer with a previously dismal prognosis, recently told me that he had treated a patient with a new kind of immunotherapy. “I think I cured my first case of myeloma,” he said. His voice was filled with awe.
This, of course, sounds like wonderful news for patients and their loved ones. And if these new treatments worked most of the time, this would be an unambiguously happy story. But they don’t.
A recent analysis estimated that about 15 percent of patients with advanced cancer might benefit from immunotherapy — and it’s all but impossible to determine which patients will be the lucky ones. Just last week, a study of lung cancer patients demonstrated the overall benefits of combining immunotherapy with traditional chemotherapy. But here, too, the researchers noted that most patients will not respond to the new treatments, and it is not yet possible to predict who will benefit. In some cases, the side effects are terrible — different from those of chemotherapy but often just as dire.
With patients and family members primed to hold onto every reed of hope, even a small chance of cure or prolonged remission will cause the majority to stick with their pugilistic approach to cancer. In our dichotomous system — one that forces patients to choose between the goal of comfort or cure — this means that most of them will forgo palliative care. We already know that despite the unquestioned value of hospice, many patients with end-stage cancer don’t take advantage of it, or do so with only a few days left in their life, having needlessly suffered for weeks or months. Our new uncertainty will probably make this worse.
What can we do to alleviate this? First, it turns out that many patients can benefit from palliative approaches even as they continue aggressive treatment for their cancer. In 2016 the American Society of Clinical Oncology recommended that concurrent care — palliative and active cancer care delivered at the same time — be made available to patients with advanced cancer. Rules that force patients to choose one approach or another, particularly those that tie insurance coverage of palliative care or hospice to stopping active cancer treatments, should be scrapped.
Second, doctors need more training in how to have these hard conversations with patients in light of the new cancer treatments. Doctors will need to become more at ease with the prognostic ambiguity and better versed in the possible benefits and harms of the new therapies.
Finally, through the federal Cancer Moonshot program, the government is spending hundreds of millions of dollars to study immunotherapy and other emerging treatment options for cancer. The sooner we can work out which patients will — and just as important, won’t — benefit from these approaches, the better.
Sadly, for some patients, a cure will prove elusive. As we continue to chase progress in cancer, let’s be sure that we don’t rob dying patients of a smaller, more subtle miracle: a death with dignity and grace, relatively free from pain and discomfort.