12/25/2015
Vincent Devita,former Director of NCI,MSKCC and most recently emeritus at Yale Cancer Center who was a central figure in the development of curative therapy of Hodgkins Disease as well as early stage breast cancer has written a fascinating memoir and history of cancer care in US through his experiences. Many reviewers have focused on his early experiences at the NCI and the cast of characters central to the evolution of modern chemotherapy. Missed are several crucial insights he imparts as well as his personal medical history and its humanness. He clearly does not advocate early withdrawal of treatment for end of life care in advanced cancer,believing as some of us do that there remain many options, often "outside the box" in advanced cancer. There is little doubt that in late stage cancer, with poor "performance status", following many treatments or the concurrent ravages of advanced age and non-cancer illness, that aggressive or repetitive treatments are often counterproductive and may even shorten survival and harm patients. This treatment is often driven by the patient and family's unrealistic expectations, as Jean Jacque Rousseau was reported to have said on his deathbed,"I know we are all mortal but I just wish this one time they would make an exception". I believe many americans do suffer from often very unrealistic expectations.
Despite this in non-curative setting, in the midst of a revolution in cancer treatment,with new molecularly targeted therapies as well as the explosion in the immunotherapy of many cancers,the ability to prognosticate is hazardous. In my book,the Cancer Recovery Plan,I wrote about cancer prognosis and "the Mutual Fund Rule",to explain why hope is in fact realistic and prognoses often given patients are wrong. As the rule states,"past performance is no guarantee of future results"! While your fund may go down after stellar performance,necessitating this statement,in cancer, the prognosis of most cancers in the future is better, NEVER worse. Yet all MD's who attempt to prognosticate have only past performance to guide them. Very often we may be encouraged to recommend hospice care to patients with " six months to live". This can only be determined at the time of death,RARELY 6 months before. This is Devita's point. Keep fighting for your patients until it is clear you will hurt them more than help them. My Yale colleagues who are in the forefront of immune therapy of advanced cancer will often consider treatment in advanced late stage disease in ill patients, recognizing that outcomes are unpredictable and occasionally remarkable, even in a group who would not be considered for chemotherapy. We are now in a phase of cancer care where the rapid paradigm changes are making it important to appreciate this crucial point.
- Dr. Barry Boyd
