Wednesday, June 28, 2017

Upstream Palliative Care and Dissecting Hope From Hype in Oncology

by Christian Sinclair

Working in an outpatient cancer center, I frequently encounter the conversation about whether the next cancer treatment regimen is ‘worth it.’ Patients and families consider may interpretations of worth; financial being one of course, but also physical side effects, the emotional toll of investing faith into ‘one more treatment’ and hoping that it works. These conversations are challenging as they weigh biological, medical, spiritual, social, personal, emotional and other issues, so there is no neat equation which can easily tell you if the benefits or the risks are greater.

These struggles were nicely summarized by Liz Szabo (@LizSzabo) in her article “Widespread Hype Gives False Hope to Many Cancer Patients.” From hospital billboards that emphasize eliminating cancer, to multitudes of ads for new drugs with new indications are we entering a hype boom in cancer care or have we really reached the next level? Szabo has this amazing quote form the CMO of the American Cancer Society:

“I’m starting to hear more and more that we are better than I think we really are,” said Dr. Otis Brawley, chief medical officer at the American Cancer Society. “We’re starting to believe our own bullshit.”

(A quick aside, I appreciate his frank assessment and swearing. This is not some vanilla, focused-group response. Also, thank you Kaiser Health News (and CNN) for actually publishing it without asterisks)

What is causing this new level of excitement in oncology? Jennifer Temel recently noted that the therapeutic nihilism started to change with the emergence of genotype targeted therapies like tyrosine kinase inhibitors in the mid-2000’s. Her opinion piece in JCO on the Prognostic Uncertainty in the Modern Era of Cancer Therapeutics echoes what I have heard at last year’s Palliative Oncology Symposium, and the Cancer Center Business Summit, as well as what my fellow oncologists are saying as we see patients. But cancer therapy has historically been through boom and bust cycles of hype, how is it possible to tell if this is any different?

Pinned Tweet of Dr Prasad
Another great voice to listen to is Dr. Vinay Prasad (@VinayPrasad82) who constantly applies the screws of scientific theory to poke holes in over-optimistic press releases from drug makers and academic medical centers about the next big drug. Follow him on Twitter and you’ll quickly learn a lot of the hype is not necessarily backed up by the strongest evidence, despite what you may see on TV or even in journals. I would imagine given the modest evidence-base in palliative care he would take the same approach to us, yet I have found his explanations helpful to me as a palliative care doctor working upstream in an academic cancer center where every week I am seeing patients on brand new drugs or relatively new drugs with new indications.

For those of you working in more upstream palliative care in outpatient settings or in the community, how are you keeping up with the latest therapeutic advances in oncology? I see that I have needed to learn a lot in the last two years in this new position and see a new challenge for upstream palliative care.

If you are interested in talking more about this, join the #hpm monthly tweetchat tonigth Juen 28, 2017 at 9p ET and join the Facebook Group started by journalist Liz Szabo 'Treating Cancer: Hope vs Hype.'

Dr. Christian Sinclair is a palliative care physician at the University of Kansas Cancer Center, editor of Pallimed. When not reading up on the latest imboblumimab, you can find him walking his dog Spud to the park.

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