Something must be done – but maybe not chemotherapy?

Peter Wise explored ethical issues relating to chemotherapy drugs – suggesting that “despite considerable investment and innovation, chemotherapy drugs have had little effect on survival in adults with metastatic cancer.”

My rapid response was thought good enough to get into the paper journal (I’m excited cos lots more people read it there!) But in case you missed it there, here it is below:

Something must be done – but maybe chemotherapy isn’t the only option?

Peter Wise’s thoughtful analysis of the limited usefulness of chemotherapy drugs in patients with metastatic cancer raises many important issues.(1) Surely we need to look wider, though, and better include patient and family views?

Steve Hewlett, for example, “gets it” that a survival benefit of only a few months may not be funded from a health economists point of view, but is understandably certain that “for those for whom it does work the benefit is much more”.(2) It’s not just Mr Hewlett who thinks like this – there’s frequent and massive media coverage of individuals fighting for NHS or charitable funding for various, including last-ditch, cancer treatments.

The point here, I think, is how compelling the idea is that ‘something must be done’.

It’s not enough to point out how rare, after the funding appeals, are the sorts of miraculous outcomes that were hoped for. And it’s not that useful to get into arguments about withholding treatments.

Instead, surely we need to argue for evidence-based, positive interventions?

This week’s Editors Choice recognises that so-called supportive care may give patients a longer life, as well as a better life.(3) This has been known since at least 2010 (4), but it still feels like a rather-too-well-kept secret.

Why don’t ethical committees better recognise the value of supportive care?

Duration of survival is not the most important outcome for all patients, but even if survival is going to continue as a primary response marker, where are the trials comparing survival with supportive care and after chemotherapies, especially the second or third line interventions?

Some of this is about the sort of commercial interests that McCartney has written about.(5) Much of it is also about doctors and “how they get locked into a curative role”, apparently under pressure from families and patients.(6) Van den Bulck has discussed how TV fiction has helped create an “illusion of efficacy”, in which “doctors are not powerless and … treatment does not stop”.(7)

But maybe I’m most worried about cancer research funding, including by the charities. After all, less than 0.3% of the £500 million spent on cancer research is allocated to palliative care.(8)

This is even though, whatever the advances, in the long term we’ve still got a 100% death rate.

1. Wise P. Cancer drugs, survival, and ethics. BMJ 2016;355:i5792

2. Wise, J. “I am positive but not irrational”. BMJ 2016;355:i5975

3. Godlee, F. Too much chemotherapy. BMJ 2016;355:i6027

4. Temel, J et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer N Engl J Med 2010; 363:733-742

5. McCartney, M. We save pennies, profiteeers rip us off. BMJ 2016;355:i5808

6. Willmott L et al. Reasons doctors provide futile treatment at the end of life: a qualitative study J Med Ethics doi:10.1136/medethics-2016-103370

7. Van den Bulck J, Damiaans D Cardiopulmonary resuscitation on Flemish television: challenges to the television effects hypothesis. Emerg Med J 2004;21:565-567

8. Higginson, I. Research challenges in palliative and end of life care. BMJ Support Palliat Care 2016;6:2-4

Competing interests: No competing interests

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