Friday, July 11, 2008

Musings on futile cancer treatments, sort of

The Journal of Clinical Oncology has an 'Art of Oncology' piece about 'futile gestures' and giving patients unproven, last-ditch treatments. It discusses this within a story about a patient for whom the oncologist did this with stunning results (put the patient's uber-refractory AML into remission allowing her to have a stem cell transplant - the patient has since remained disease-free); he notes that prior to giving the treatment he thought the chance of it working was less than 1:100. What is interesting about the piece is the author's own acknowledgment and self-reflection about the fact that what he did was 'wrong' - something he would have advised a colleague against doing, one that he knew went against best practice and EBM, but he ended up deciding (without knowing of course how 'luckily' things would turn out) that sometimes 'futile gestures' are good patient care. He has this to say:

Any antineoplastic treatment she would get would almost certainly make her feel
physically worse. But psychologically she was having understandable difficulty,
and though it would come at the cost of the adverse effects of therapy, she made
it clear that her mental state would improve with going back on active
treatment. I told Marni, when asked, that this was a trade-off I myself would
probably not have accepted. However, more treatment almost certainly was
quantitatively futile. After four failed attempts at inducing a remission, I
felt the chance that any medical therapy could affect her leukemia, and
therefore help her live longer, was vanishingly small. If pressed to quantify,
lower than one in 100 was a reasonable guess. I have always believed, as Harnett
and Moynihan suggested in a previous Art of Oncology piece, that continuing
toxic therapy in the hope of some response is inadequate medicine. Yet, as Ewer
pointed out, our prognostic acumen is often insufficient to predict which
patient will defy statistical odds and improve when, by all subjective and
objective criteria, it is beyond the realm of possibility. This thought
lingered. Always quick to acknowledge the limitations of my own knowledge, I
wondered. Was there a therapy somewhere that could help Marni Adams?

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