“Can you hear me now??!!” The “dialog” in room 1 became comical as Lillian and Bob between them only managed to have one working hearing aid. I am yelling, they are confused, and writing didn’t work because they forgot their glasses as well. The O2 tank and 2 walkers add to the environment. Half way through we collapsed giggling. But for Bob and his bride of almost 70 years this is no laughing matter.
As we stumble to get there, the discussion must include their input, not just review of scans and therapies. Cancer care is changing rapidly. I’ve mentioned immunotherapies for the hardest to “cure” diseases, stereotactic radiation to small lesions, with improved survival even for metastatic disease, various combinations of chemo and antibodies for many diseases, less invasive surgeries, and developing radio-nuclides. The depth and breadth of growth in the field is logarithmic. Because there are national guidelines, your docs know the latest and greatest. That is where you come into the equation. For the past years I have discussed here the need to be your own advocate. As we are aging and cancer is becoming more ubiquitous (the leading cause of cancer is age), your choices are just as critical as the plethora of options.
At 86 and 87, this lovely couple must make decisions right for them. Enter breaking news from ASCO this week. Three physicians are investigating new lung cancer therapy that can be effective and have low toxicity. Dr. Jessica Bouman from Fox Chase Cancer Center (where I was their first dietitian in the 70’s!) Dr. Julie Rotow of Dana Farber Cancer Institute and Alessio Cortellinni Bio-Medico University Rome, are considering the approaches of the standard combination chemo, vs less toxic mono therapy (one drug, such as Tagrisso). It is critically important for research to move in the direction of efficacy and convenience with low toxicity. Oncologists are managing an aging population who understand that longevity has already been attained, now it is a quality issue. Many of the medical oncologists I work with evaluate each individual for the best option, encouraging patient participation in the decision. It is perfectly okay to ask your physicians, as Lillian and Bob did with me, “What is the least I could do and still have some therapy, if not the most aggressive. Since at this point, it won’t change my longevity, but do not want to ruin whatever quality of life I have now”? Fair question. Make it easy on yourself. Ask the Doctor, what the most aggressive and effective plan of care is for your disease, and then also, what is the minimum that could achieve some benefit or even palliation. For Bob we came up with a 5 treatment course of stereotactic radiation to the lung which will be very well tolerated (and effective) then monotherapy by the medical oncologist. It is important to have at least one loved one with you so they can hear the discussion and also understand your own goals.
Every single chart note about you involves your “fitness status”. (No, not how long you hold a plank.) The ECOG* score must be stated in your record. It is a measure of fitness to treat today and considers age, other illnesses, strength and factors critical to the decision. (Like can you put your own pants on in the morning). Cancer guidelines are interesting but just a guide. None are carried out without consideration of the individual patient. If you are caring for a loved one with cancer, be there for those discussions.
We are not here to bully you into therapy. We, as your docs, need to know your goals and then advise our best recommendations. So many of my patients remind me, “Doc, a long life is just long, but a good life is good.”
*www.mdcalc.com ECOG performance status