Don’t Let Oncologists Make All the Decisions

Many cancer patients spend their last days undergoing treatments that both oncologists and hospitals know will give them a few extra weeks, at best a couple of months. The medical evidence is clear. Yet 20 percent of patients with solid tumors receive chemotherapy during their final two weeks of life.

Oncologists just aren’t trained to break the brutal fact that the chances of cure are always near zero for patients with metastatic solid tumors. Thus, most cancer patients have “unrealistically optimistic expectations regarding their prognosis and response to therapy,” two candid oncologists wrote in the most recent New England Journal of Medicine. One study in the article showed that lung cancer patients expected to live more than two years even though the average length of survival is about eight months.

Without knowledge, patients cannot make informed choices about continuing chemo. Hospitals have a role to play here: they should ensure that patients have access to palliative care specialists who are trained to talk about odds, risks and benefits, and, most important, draw a patient out to express her desires.

Too many hospitals let oncologists decide whether a palliative care team can see someone he views as “my patient.” Why? Not long ago, a Manhattan palliative care specialist told me that hospitals are afraid of their “rainmakers” (physicians who bring in well-insured patients). So the oncologist is allowed to block the consult, while ordering more chemo. Over half the profits in oncology flow from drug sales.

Meanwhile, the cost of cancer care spirals from over $104 billion in 2006 to a projected $173 billion in 2020. U.S sales of anticancer drugs are now second only to heart disease medications and most new molecules are priced at $5,000 per month or more.

Still, isn’t it worth the price -- and the suffering -- to buy a few weeks or maybe, months of precious life? Ultimately, the patient herself should answer that question, based on her hopes, fears and beliefs. To do so, she needs the facts.

“Why take away her hope?’ Because most cancer patients want to die in a hospice, or at home, with hospice care. If they don’t make plans, they are likely to spend their last days in a hospital or an I.C.U. Interestingly, recent research suggests that patients may live longer if they leave the hospital and receive hospice care.