A colleague approached me this morning and asked vaguely about a friend who has Stage IV lung cancer. He was asking whether the patient should continue receiving chemotherapy when the tumor, upon evaluation, was noted to have metastasized to another location while undergoing treatment.
Generally, when a patient is undergoing treatment and a new tumor grows somewhere in the body or the tumor increases in size, we recommend shifting to a different set of drugs. The rationale behind this is that the tumor cells are no longer responding to the current drugs and the patient will therefore, not benefit from receiving the same set of drugs.
In the course of our conversation, I felt that the looming question in his mind is whether or not there is still a point to continuing treatment. The tumor has been persistent despite successive treatments. The financial, emotional and psychological costs have already been staggering.
The Roller Coaster Ride
When patients come to us, they are hoping against all odds, that we will deliver the magical words that we will take care of everything and forever get rid of the cancer. Patients at this point, will do almost everything that we tell them. I often hear patients say “Doktora, gawin po natin kung ano ang dapat (Doctor, let us do everything that needs to be done)”.
So the patient undergoes treatment, cycle after cycle, enduring the fatigue, the nausea, the lack of appetite as well as the weekly blood draws to check on their blood count, not to mention occasional admissions to the hospital to manage more severe complications. Then comes the CT scan evaluation. The tumor decreases in size. YEHEY!!! Celebration!!!!! The news has just made everything worthwhile!
But not all patients end up like this. Some patients will be receiving a bad news.
The patients who receive the bad news will be offered another set of treatment because the previous treatment did not work. So the battle continues. Every treatment offered is a ray of hope. Every good word from the doctor is hanged-on to as the patient and their loved ones go through a roller coaster of emotions.
The Deeper Question
So the question begs to be answered. “Is there a point to continuing treatment?” Patients often expect me to answer this for them hoping to be absolved of the consequences of such a decision.
You see, cancer treatment is not as easy as the doctor writing the prescription to get rid of what is ailing the patient. Cancer treatment is a partnership between the doctor and the family. The doctor acts more of a life coach than a mentor. The doctor must help the patient UNDERSTAND, CHOOSE AND IDENTIFY THE GOALS OF CANCER TREATMENT. The doctor offers the best, the appropriate and reasonable options, gives feedback and does not make the patient feel that what he has been offered is the ONLY OPTION.
The doctor must ask questions like “What do you want to achieve?” “What is your goal for this course of action?” “What trade-offs are you willing to accept?” “What are the things that you are willing to give up?” “What constitutes acceptable and not acceptable to you?” and sometimes the defining question: “How much are you willing to spend for treatment?” The coach/doctor must then follow where the patient wants to go and guide him along the way ensuring that the he reaches his target with minimal glitches. In reality, it is the patient who decides the course of action.
So for this patient, I will ask “Do you understand you current situation?” “Have you been made aware of the RISKS AND BENEFITS OF TREATMENT?” “What do you want to achieve with subsequent treatments?” “Are your objectives realistic?” “Have you not been promised wrongly?” These questions will lead the way to answering the big question “Is there a point to continuing treatment?”