Tuesday, October 13, 2009
From my back-log of Journal of Clinical Oncology issues.
First is an editorial about health related quality of life, cancer survival, and research (free full-text here). (It's a response to this paper about HRQOL predicting survial in early stage head and neck cancer; I think most readers will find the editorial more interesting.) The editorial starts out reluctantly lamenting that the cancer research world only became interested in HRQOL as a research outcome because there has been some off/on suggestion that it predicts survival, and not because HRQOL is an end/outcome of importance by itself. It gives a little of the history of these investigations, ponders what the clinical utility of measuring HRQOL could be with regards to prognostication, and argues that patients care about more than survival and so should should cancer researchers.
What it doesn't address, and which is something I struggle with, is whether HRQOL is a fancified version of performance status (and if you look at most of the HRQOL scales - EORTC QLQ, SF-30, etc., most of the domains are to do with functional status; not all, but most). Either way, HRQOL scales are rarefied abstractions, which clearly are measuring something, but what that is I don't really know and have not been convinced (yet) that it is something materially different than functional status.
There's a fascinating study about prevailing end of life ethical dilemmas in Taiwan. Fascinating for many reasons, one of which is the opportunity to read the text of the Taiwanese 'Natural Death Act' which essentially gave legal clarification to doctors and patients that it was ok to stop unwanted/unhelpful medical treatments as patients die, and established some sort of protocol for doing it (you can read the act with the online article). I'm not sure how this is actually done in real life, but reading the act you get the sense that if patients want 'hospice-palliative care' they have to sign a form saying that (of course you do in the US too, to receive hospice benefits). It also has language which seems to say that doctors should only inform patients of their (presumably terminal) condition if the patient has 'clearly' expressed a wish for such knowledge (one can argue whether this is good or bad, but it's notable to see it in a law).
The prevailing ethical dilemmas that the researchers found (by surveying doctors and oncology nurses in Taiwan) were very familiar (artificial nutrition/hydration, patients wanting alternative treatments, etc.). The top one, by far, was truth-telling, which is certainly an issue here, but perhaps more acutely in Taiwan.
There is also a 'big picture' discussion on 'palliative cancer care', originating from an ASCO taskforce, and looking back over the last 10 years since a prior ASCO statement on palliative cancer care. Most of it is laudatory about ASCO accomplishments in the last decade, with a couple zingers thrown in (this was my favorite):
Although there has been an overall increase in the use of hospice services, ASCO has not actively pursued strategies that would increase acceptance and lead to earlier referral to afford patients and families optimal value from the Medicare Hospice Benefit and other hospice-related health care coverage.The rest of the paper outlines what ASCO aspires to do in the next ten years, with a heavy focus on integrating 'palliative cancer care' in cancer centers worldwide. All swell, but there is a distinct lack of mention of palliative care specialist services (a lot of talk of providing palliative cancer care across the continuum, some mention that specialists should be available 'when necessary,' but a noticeable absence of a hearty endorsement for the universal availability of specialist level palliative care for cancer patients). The taskforce is mostly palliative specialists who are/were practicing oncologists as well, and I don't know if I'm over-reading this absence, and if I'm not I assume it's due to ASCO discomfort with the idea and not the authors'.
This aside, most exciting to me was their recommendations for the next 10 years of goals in education, including recommending to ACGME that all onc fellows have one month training in palliative care. That would be welcomed.
And on the supportive cancer side of things, the most recent issue is dedicated to thrombosis in cancer patients, with review articles on prevention, treatment, biology, etc. I just read the consensus paper (which is a narrative summary of consensus guidelines): basically yes you probably should give prophylaxis to hospitalized cancer patients, and low molecular weight heparin is the drug of choice for treatment of VTE. They outline a research agenda: no mention about the kinda hot topic of VTE prophylaxis and treatment in dying patients and hospice patients.