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January 8th, 2014

Cancer 2014 — A Modern Spin on a Tragic Diagnosis

Paul Bergl, M.D.

At first glance, no diagnosis seems more terrible than cancer. Although it remains a huge killer in the developed world, cancer has also taken on new meanings in modern medicine. As an ordinary person, I certainly fear the word and would dread the diagnosis. Cancer. It has such a damning and unforgiving ring to it. After 3 years of residency in a tertiary referral center, where I’ve seen some of the worst cases conceivable, I still cannot imagine the painful and devastating odyssey that those who succumb to it must endure.

As a recently minted physician though, I fear cancer for other reasons. The science of the field is moving at a blistering pace. How can I keep up on the state-of-the-art treatments, genomic-based diagnostic tools, and molecular therapies? (When I talk about modern cancer care, I often wondering if I even talking about things that really exist.)

The care of cancer patients discourages this generalist, because it has become exceedingly complicated. How do I craft my words to distinguish “cancer” from “pre-cancer”? What advice do I give to a patient with recent biopsy-proven, localized prostate cancer? Will I be sued for negligence I didn’t offer chemoprophylaxis for breast cancer in a patient who develops metastatic disease on my watch? How can I watch expensive third-line chemotherapy being given to one of my patients while another patient eats his way to a cancer-causing BMI of 40 on a low-cost, high-carb diet?

Given these questions, I thought I would begin 2014 with a reflection on what cancer means to the general practitioner.

Cancer as Preventable Disease

Despite all the advances we have made in diagnosing and treating cancer, we still face awesome opportunities to curtail cancer before it even starts. During the past several decades, we have clearly made strides in preventing cancer, particularly in the realm of curtailing tobacco use. (Then again, tobacco use rates aren’t really all that different than they were 10 years ago.) And, all the while, our nation is growing increasingly obese  so much so, that obesity threatens to overtake tobacco as the major preventable cause of cancer.

Given these trends, I sense that progress toward preventing cancer has stalled. I also wonder if enough clinicians are even considering the fact that cancer is preventable at all. When I give the lifestyle pep talk in clinic, I am usually warning patients about risks for developing cardiovascular disease or diabetes, not cancer. I also feel somewhat powerless to affect a patient’s ability to avoid cancer through lifestyle interventions.

These days, we need continued dedication to training physicians to coach patients about lifestyle improvements. We also must bridge the divide between medical providers and our public health leaders and find more creative solutions than exploding cigarette taxes or rehashing ideas about food deserts, fat taxes, and junk food advertisements.

Besides preventing cancer by recommending lifestyle adjustments, the generalist must also augment his use of chemoprophylaxis when indicated. For example, even though the USPSTF reaffirmed its grade B rating for chemoprevention of breast cancer in high-risk individuals in 2013, most of us don’t adhere to these guidelines very stringently (NEJM JW Womens Health Apr 8 2010), especially compared with our adherence to other grade B recommendations, like mammography. We will have even more options as aromatase inhibitors emerge as chemoprevention, so we generalists will need to keep up to speed in this field. Of course, we might be able to use less targeted chemopreventive techniques, like aspirin for colorectal cancer and will need to know the risks and benefits of these options, too.

Less Screening and More Expectant Management of Cancer

Although oncologists might argue that “targeted therapy” or “pharmacogenomics” are the buzzwords that describe the future of cancer care, my own generalist-biased ears hear “overdiagnosis” everywhere. Most clinicians probably think of indolent prostate cancer and the PSA debate when they hear this term, but plenty of buzz surrounds overdiagnosis for other reasons. Part of the issue is the desire to redefine clinical entities that have often come with the bleak label of “cancer.” For example, the debate over DCIS has shifted from how to treat it to how we even describe it to patients. And, clearly, what we call DCIS does matter.

We also have new screening modalities that have generated excitement, such as the USPSTF and American Cancer Society’s endorsement of low-dose chest CT for lung cancer. Clinicians must remain circumspect about use of this screening tool though, as chest CT itself can reveal countless false positives and also carries serious risk for overdiagnosis. And, like the PSA/prostate cancer debate I’ve seen unfold over my training career, low-dose chest CT can lead to expensive, debilitating, and potentially deadly complications from biopsies and excessive cancer treatment.

All of this talk of overdiagnosis also makes me wonder where the medical community will draw the line on whom to screen. I wonder how willing the public will be to accept expectant management as a treatment option. The American Cancer Society already has published patient information for managing prostate cancer expectantly, but how often will patients with something more deadly — say, lung cancer — opt for “just watching it”?

Cancer at the Crux of the Medical Economics Arguments

Finally, all of these cancer-related issues are bound to intersect at the most timely of all topics in medicine: cost-effective care. That cancer care is extremely expensive is no secret. Thus, we will need to be more selective in our use of cancer treatment modalities. Will our payers begin to curb use of treatment modalities that do not confer a defined benefit for their cost, such as radiotherapy for prostate cancer? And on the question of cost-effective screening, will we continue to find more cost-effective ways to identify cancer early (like HPV testing every 5 years for detecting cervical cancer)?

Cancer 2014

Cancer is no longer the ultimate evil that must be detected early and destroyed at all costs. I don’t know that it ever was, but I do know that decision-making around prevention, detection, and treatment of cancer has become more nuanced than ever before.

2 Responses to “Cancer 2014 — A Modern Spin on a Tragic Diagnosis”

  1. Jeffery Bandola MD says:

    After 32 years as an internist in solo practice I closed my office to concentrate on geriatric and palliative care. It is a relief to be free from the burden cancer screening, most of which struck me as burdensome and largely ineffective. As a cancer survivor myself (seminoma at age 41) and a veteran observer I will try to convey some of what I have found important.

    The natural history of cancer is like opera, with much for the patient to assimilate in the first act. This is the time to extend yourself personally to your patient and reach out to the supporting family members. I ask for the spouse to be present for the first visit when I make the diagnosis and discuss treatment. When giving bad news I always sit at eye level and speak slowly, avoiding jargon. Allow time for questions. Write the diagnosis down on a paper and hand it to the patient. You will find that they are not surprised, and accept your words with striking equanimity in nearly all cases. Touch their shoulder or arm or grasp their hand. Self-disclosure here is OK.

    One thing I always do is look at the spouse and ask them how they are doing, and then say that in many ways it is easier to be the victim than the spouse because the victim is given freedom to act and feel as they wish, while the spouse’s script comes right out of an old Jimmy Stewart movie: tireless, devoted, selfless, optimistic and tireless. Give them your cell number, and stay in touch by an occasional phone call as they are devoured by surgery and oncology. That muddle represents acts 2 and 3. With luck they will survive and leave the theatre before curtain call.

    For many, though, we come to act 4, when we reappear, sometimes called in by the spouse to discuss a gathering sense of futility, or to treat an intercurrent illness. At some point it is apparent that treatment is no longer effective. It is our role to push back against futility and talk honestly and directly about death. In opera the emotions peak and the music builds to crescendo as the final scene approaches. So to in cancer, the sense of an implacable momentum cannot be ignored, and our skills of consoling and pain management are most needed. I tell my patients lucky enough to have an intact sensorium at this point that I will not let them suffer. I make a case for acceptance, and speaking from the heart to those they love, to say those things many find it hard to do otherwise. In the nursing home at this point I make frequent short visits, asking if they have pain, or are they frightened, or cold, always touching a hand or a shoulder. I commend family members on making the right decisions and for being there at the end. How many times I’ve told grieving women that they are wonderful daughters or wives, I will never know.

    Terminal care of a long-term patient is intimate in a way that surpasses anything else we do as physicians. We must nurture our skills here and use them with wisdom and humility. That is our sacred role.

  2. Lesli says:

    Thanks for sharing your thoughts on cancer.
    Regards

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