From the Grace Archives | Originally Published July 30, 2011 | By Dr West
Our weekly thoracic tumor board, a multidisciplinary meeting with multiple specialists in thoracic oncology all converging together to discuss management possibilities for challenging cases, has long been a highlight of my experience at my institution. I really enjoy working with my colleagues, and we have good discussions that sometimes reach a clear consensus but are always thought-provoking.
I wrote recently about the challenging theme of balancing overtreatment vs. undertreatment in patients with locally advanced NSCLC who might or might not benefit from surgery after chemo and radiation. But another extremely common case we get, and which has become a source of heated discussion to the point of raised voices, is the person referred out of desperation felt by the referring doctor and/or patient with what is generally considered incurable disease for “Hail Mary” surgery or radiation, or both.
Historically, some patients have undergone metastasectomies (surgical removal of metastases), and manuscripts in the surgical literature have consistently shown that some fraction of cherry-picked patients can do very well for a long time, with years of long-term survival. These same reports have consistently shown that the people who do best have an unusually indolent cancer (multifocal bronchioloalveolar carcinoma has been among the cancers for which surgery has been pursued), often with a prolonged disease-free interval between initial cancer diagnosis and treatment and then subsequent appearance of the metastasis (or metastases), and fewer metastases/areas of active disease.
What all of this work essentially shows is that people who have many features that already predict for an unusually favorable outcome compared with other people with metastatic/recurrent disease can continue to do well, possibly because of, but also potentially despite, more aggressive treatment that has no proven role. The people who have an unusually slow-growing cancer will often be alive and doing relatively well many months or a few years later, but that’s exactly how they found their way to the more aggressive care: the people with widespread metastatic disease that followed the more typical statistics never had the opportunity to pursue surgery or stereotactic radiation. And even beyond the factors related to the disease, the patients most likely to seek and be offered more aggressive treatments are the youngest, healthiest, and most aggressive people — factors that also correlate with doing better regardless of the treatments pursued.
There is certainly a chance that these treatments are helpful, but we really don’t know. What we do know is that there are many incentives to pursue them, from all sides. First, of course many patients want the most aggressive treatment possible: “I just want it out” is something we hear commonly, and many patients and caregivers mistakenly presume that surgery is somehow the magic key to cure — while there is more people being cured after surgery than after other treatments, this is very much a product of the fact that surgery is appropriate almost exclusively for patients who have a chance to be cured, while chemo and radiation recommended for much broader populations, including who many who we can’t realistically consider being treatable with curative intent right from the time of their diagnosis.
Second, doctors involved in their care also have a few incentives to advocate for more aggressive care than has an established value. They want to give their patients the benefit of the doubt, to give them the chance to do unusually well. At the same time, like patients and caregivers, they/we share a mentality that more is often better (at least in the US), and at the same time it’s often easier to just offer more than to have the difficult conversations and accept that metastatic disease isn’t likely to be curable — we offer surgery and radiation because it’s the feel good easy answer, the medical version of a politician’s pledge to lower taxes and promise prosperity. Still, our surgeons and radiation oncologists convey that it’s not rare for them to receive referrals from doctors or patient self-referrals that are simply ludicrously inappropriate.
And beyond that, physicians often have a good financial incentive to treat beyond the conventional standard of care. Surgeons are paid to do surgery, radiation oncologists are paid to do radiation — and the institutions where they work also typically profit and gain market share by offering treatments beyond what is considered a standard of care, especially since many of these treatments like stereotactic radiation are among the more expensive and profitable treatment offerings.
When I raised the point that I was concerned we were offering surgery and radiation to people who have essentially no realistic chance of benefiting from them, one challenge I received was that later lines of chemotherapy and targeted systemic therapies are truly no different: we provide them not because of the compelling evidence of benefit, but because people all but demand them, we hope that they might help, oncologists are often incentivized (i.e., paid more) to deliver treatments, and because it’s easier to offer one more line of treatment than to invest the time and emotional energy in a difficult conversation that you know most patients and caregivers don’t want to have, even when it’s appropriate or even necessary. In fact, futile chemotherapy for people with a poor performance status and/or already heavily treated is one of the identified culprits for the extremely rapid rise in costs of cancer care and one of the identified ways to cut costs without compromising survival. So medical oncologists are certainly not immune, and even if I argue that light weekly chemotherapy is less toxic and therefore perhaps more permissible than a futile surgery, it’s not always less expensive, and I can’t argue with conviction that this isn’t just a rationalization. Moreover, it’s not as if I’ve never recommended surgery or radiation for unusual and ambiguous cases: I just judge that mycases are more appropriate than the more egregious ones that are sometimes discussed. But yes, it’s a slippery slope.
The consequence of this probable over-treatment of many patients is not just that they are receiving the risks and adverse effects of treatments for which we all, patients and doctors alike, collude to over-imagine the benefits and under-appreciate the negative aspects, but also that we’re just burning money on treatments that don’t end up helping people. I know that to most readers, concern over societal costs of care for their cancer or that of a loved one isn’t a factor, but more health care organizations are being shifted to new models that no longer reward doctors and institutions for more treatments, especially without an identifiable benefit, and may even penalize them for it. In that case, would doctors be as inclined to pursue treatments without a clear role, largely because patients and families seek them? I suspect there would be a big shift in treatment patterns.
Moreover, these kinds of interventions may be viewed more critically before being covered by payers. If these interventions weren’t covered and then passed on to the rest of society, I don’t know that patients and caregivers would be anywhere nearly as inclined to front the costs of treatments that cost tens or hundreds of thousands of dollars with dubious benefit. Is the hope of a possible benefit enough to seek a treatment if payers only covered the treatments that have a proven role?
Finally, I’ll conclude by saying that I know these issues hit close to home for many people here, and I don’t mean to disparage or trivialize any of their efforts. As I convey above, I follow my own judgment and often recommend treatments beyond the proven established ones. We all have our own complex interpretation of risk, benefits, and resource allocation. But I think we need to step back and acknowledge the complexity of so many factors, as well as our own biases. At the very least, it’s worth remembering that more is not always better.
We may well be wrestling with many new questions in coming years, reflective of changing incentives in health care.
I welcome your thoughts and hope I’ve only pushed the right buttons to get people thinking but not reaching for pitchforks and torches.