Wednesday, September 2, 2009

Huckabee, Kennedy, and the Politics of Distortion

Former Arkansas Governor, Mike Huckabee, speak...Image via Wikipedia

The Huffington Post reports that former Arkansas governor Mike Huckabee thinks that under President Obama's healthcare plan, Senator Edward Kennedy might have been required to forgo disease-directed therapy for his glioma (surgery, chemotherapy, etc), instead being forced to receive only comfort oriented care from the time of diagnosis. Furthermore, he infers that this approach would have resulted in a "quick" death:
"[I]t was President Obama himself who suggested that seniors who don't have as long to live might want to consider just taking a pain pill instead of getting an expensive operation to cure them," said Huckabee. "Yet when Sen. Kennedy was diagnosed with terminal brain cancer at 77, did he give up on life and go home to take pain pills and die? Of course not. He freely did what most of us would do. He choose an expensive operation and painful follow up treatments. He saw his work as vitally important and so he fought for every minute he could stay on this earth doing it. He would be a very fortunate man if his heroic last few months were what future generations remember him most for."
Senator Kennedy's death has been politicized by many on all sides of the healthcare debate. Politics aside, though, anyone in the field of hospice and palliative medicine (and many others) can see the obvious errors in Huckabee's thinking. I hope to add to the internet "chatter" that refutes his claims because I don't think there can be enough chatter on this side of the issue.

Let's assume that Sen. Kennedy's diagnosis was glioblastoma multiforme. While we know that he had a "successful" surgery (unclear how success was defined), I don't know what other therapies he received. But here are some studies related to gliomas:
  • In a small randomized trial, patients older than 65 were randomized to receive resection of tumor vs. a biopsy. All subjects received radiation therapy. Median survival in the surgery group was 5.7 months vs. 2.8 months for the biopsy group.

  • In one randomized trial that looked at the role of adjuvant radiation therapy for older patients (>70 years old) with glioblastoma multiforme, the median survival for patients who received radiotherapy plus supportive care was 29.1 weeks, as compared with 16.9 weeks for patients who received only supportive care. The regimen studied was 50 Gy in 1.8 Gy fractions, in other words, about 28 treatments.

  • Non-clinical trial data suggests that temozolomide may confer a survival advantage to older patients of a few months on average. It's an oral agent that is taken for five consecutive days every 28 days.
In other words, the "average" older person will gain some months with these therapies (perhaps longer for some, and much shorter for others) with the possible adverse effects and inconvenience associated with the therapies. Side stepping any controversy regarding what the standard of care should be, let's assume that these therapies do indeed stand a chance to prolong a patient's life. That's great, although obviously, we're not talking about curative therapies as Huckabee states. Everyone (regardless of age) should have the opportunity to discuss the merits and drawbacks of these therapies in their individual circumstance. None of the proposals, including anything that Obama has mentioned or HR 3200 Section 1233, would preclude a patient (including an older patient) from choosing these therapies. Let's also remember that primary brain tumors are not unique to older patients and let's hope that those who do not qualify for Medicare or Medicaid have adequate insurance coverage to cover these expensive therapies in a timely manner (when they are desired by the patient.)

Huckabee may accurately state that most of us would elect to proceed with at least some of these therapies. The operative word is most, and given the statistics above, a significant proportion might be inclined NOT to proceed with the therapies (as Huckabee quotes Obama as saying although Huckabee's inference is that the "government" would make the choice for the patient). Furthermore, some may not be candidates for the therapies because of comorbdities or advanced stage at diagnosis. The common denominator amongst all patients diagnosed with this is that they will be burdened with symptoms and eventually die from their disease: A population that would be well supported by palliative care. Palliative care should not only be the alternative to disease modifying therapy when the physician obtains informed consent, it should be the standard of care regardless of other therapies offered. Any legislation that bolsters palliative care efforts will be good for every patient with this diagnosis.

It's plausible that Kennedy received disease-modifying therapy up until the very end, but there's little doubt that he and his physicians put limitations on the intensity of attempts at life-prolongation towards the end. He died at his home and one can reasonably assume that he therefore did not undergo resuscitative measures, likely after an "advance care planning" discussion with his physicians (or maybe his lawyers) perhaps even before he was diagnosed. In other words, he probably stayed at home, took pain pills, and died. Who would argue with this approach (since most Americans would prefer to die at home and all want to be comfortable) and who would accuse him of "giving up on life" in the process of doing so? Which patient wouldn't benefit from an early discussion to clearly delineate what preferences they have for such therapies near the end of life, regardless of what those preferences might be? This is the intention of HR 3200 Section 1233.

As with Christian's recent post, pain medications and death are once again juxtaposed inappropriately. I've not known a patient with this diagnosis that didn't benefit from pain medications long before they died, and the cause of death in the end has always been the brain tumor or some other complication.

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