LETTERS TO THE EDITOR
TO THE EDITOR
Having read with interest H.A. Frank and T.M. Davidson’s article,’ we bring to your attention the following commentary: Workers in the field of oncology have learned that only an aggressive surgical treatment may ammeliorate the prognosis for most patients with head and neck cancer (excluding glottis carcinoma). Chemotherapy is beneficial for systemic malignancies, such a s Hodgkin’s disease or lymphomas, but has proved to be of limited efficacy in most head and neck carcinomas. Despite seemingly adequate primary therapy, a large number of patients experience recurrent disease, and salvage of these patients is usually a rare event. The cardinal question facing us under these circumstances is whether recurrence is the correct time to free the patient from the therapeutic burden or is an imperative for further struggle and extended use of drastic oncologic therapeutic measures. The humanist will state that the physician lacks the ability to guard the holy integrity of the soul and body of this very sick patient and must at this point leave the “wrestling ring” and discontinue his useless, tormenting medications. This philosophy of “leave him in peace” is not always completely free from economic and financial considerations, especially with regard to medical insurance companies and interested medical investors. Others, on the contrary, may think that every measure, even extreme, should be undertaken to give the patient even the smallest chance. The latter group believes that physicians should make treatment decisions regardless of economic considerations. The patient generally lacks decision-making ability at this stage and usually depends on his physician for advice. He asks to be patronized and guided by his doctor in this labyrinthine pathway of pain and suffering. The trivial daily tasks and choices like eating, drinking, or clothing are no more a matter of personal decision but rather a hospital team’s decision. The patient is tired and exhausted easily. Is there a problem of overtreatment in the oncologic patient with recurrent disease?
182
Letters to the Editor
Although the percentage of “five-year survivors” has grown during the last decade, the problem of recurrence remains nearly without therapeutic response in most cases. It can be stated that the increased survival rate after concentrated treatment of the primary tumor is paralleled by an increasing number of recurrences. Recurrence usually requires a more thoughtful decision-making process than the initial treatment, as surgery is more deformative, the physiological conditions are poorer, and cure is seldom encountered. In October 1988, during a conference of the Israel Society of Oto-Laryngology, the problem of the “overtreated patient with head and neck carcinoma” was brought up for discussion. We presented our results in two groups of patients with cancers of the larynx, oral cavity, hypopharynx, and sinuses with similar TNM staging. Both groups had undergone multiple ablative operations, followed by chemotherapy, irradiation, and plastic surgery. In one group, patients died within 10 to 30 months, with inumerable episodes of local recurrence, long hospitalizations, physical pain, and psychological torture. The patients in the other group experienced similar lengths of survival but were hospitalized for only short intervals, with a fair quality of life. Is modern medicine developing the syndrome of the “overtreated incurable patient?“ The subject is heavily in dispute and raises philosophical, medical, ethical and socioeconomic questions, as therapy for recurrent cancer is associated with considerable uncertainity. Disappointment plagues us, leading us to sometimes abandon the patient to suffer his last long months with misery. Experience as reported in the current medical literature is mostly irrelevant and provides few guidelines. The extreme variations in survival rates offer an element of hope, and I often feel morally obligated to plan and perform a therapeutic regimen for the incurable patient. I conclude with the following: (1)In our series, radiation or cytotoxic therapy following repeated surgery a t the primary site was not successful in controlling the recurrent disease. (2) No patient with recurrent disease remained alive for more than 10 to
HEAD & NECK
March/April 1990
30 months, although some maintained a fairly good quality of life. (3) For extreme illnesses, extreme treatments are most fitting (Hippocrates’). (4) When the physician is unsuccessful in his therapeutic measures, he should try to understand the message of the incurable patient-If he wants to fight, fight with him; If he doesn’t, try to relieve his pain and torment. Y. Zohar, MD M. Strauss, MD Department of Otolaryngology and
Head-Neck Surgery Hasharon Hospital Petach-Tiqwa, Israel
1. Frank HA, Davidson TM: Ethical dilemmas in head and neck cancer. Head Neck 11:22-26,1989. 2. Goepfert H: Are we making any progress? Arch Otoltzryngo1 110562,1984. REPLY:
The comments by Drs. Zohar and Strauss raise a number of issues that were addressed in part in our article. These are: 1. Is recurrence of cancer after appropriate primary treatment the time to consider withholding further treatment? We believe that whether to treat and how to treat should be thoughtfully considered and thoroughly discussed with the patient both initially and a t the discovery of recurrence. The possibility, the probability, and the significance of recurrence should be part of the initial discussion. This allows the patient to correlate this information with his or her goals and values in order to reach a decision in collaboration with the physician on how to proceed with treatment in the best interest of the patient. 2. To what extent should and do economic considerations enter into treatment decisions? Formerly, consensus was that economic aspects had no place in treatment decisions; however, this is now a controversial area. It appears to us that patients do on occasion appropriately decline expensive therapy with limited chance of success out of concern for impoverishing family members they will leave behind. That is their decision, and we believe it should be honored. When economic restraints are pressed on the decision process by public officials, insurance companies, or the administrators of hospitals and HMOs, we believe the physician should be the patient’s advocate. This is often difficult because such advocacy may place the physician in jeopardy with the institution in which he or she works, thus creating a conflict of interest. We are all coming to recognize that there are finite limits to the total quantity of medical care that society can afford and that these resources are not equitably distributed amongst all persons needing medical care. If economic restraints are to be placed on treatment decisions, we believe these should be made a t the soci-
Letters to the Editor
etal level and should apply to everyone. Individual physicians should not make these decisions with respect to individual patients. 3. To what extent do patients lack the ability to make informed decisions about their treatment? To what extent should physicians decide for them? Current consensus, supported by current law in the United States, is that, except in emergency situations requiring immediate decisions and actions, most patients can and do make appropriate decisions when properly informed. Information requires continuing dialogue as we pointed out in our paper. In head and neck cancer, there is clearly time to reach such decisions if the process is begun at first contact between doctor and patient. We believe it is rarely, if ever, necessary or appropriate for a physician to make decisions without collaboration with the patient or a suitable surrogate. 4. Is there a problem of overtreatment in the cancer patient with (and without) recurrent disease? How does one balance increased length of survival against decreased quality of life? We believe there is indeed overtreatment, perhaps frequently. This occurs for the reasons we discussed in our article: economic and academic interests of the physician; personal fear and lack of acceptance of death; evaluation of the balance between longevity and quality of life which differs from the patient’s; and religious beliefs. In each individual case “overtreatment” and “undertreatment” are difficult to define. This definition must be approached through consideration of the patient’s goals and values. 5. Are we morally obligated to pursue cure in the face of minimal hope of success? We believe the answer is no, if to do so is not in the patient’s best interest as defined by the patient. 6. Do physicians abandon patients when cure is impossible? Unfortunately, the answer is yes. Physicians sometimes feel inadequate or guilty if they fail to cure. Physicians who have not accepted their own inevitable death fear it and avoid dying patients. Physicians are educated and trained in curative medicine. They are often poorly trained in supportive medicine for patients with chronic and terminal illness. As a result, they feel uncomfortable and inadequate when called upon to offer comfort care and all too often back away from it. The result is psychological if not physical abandonment of dying patients. There is an oft-quoted aphorism from 15th century France: “To cure sometimes; to relieve often; to comfort always- that is the physician’s role.” We thank the commentators for giving us the opportunity to discuss the questions they raised. Hugh A. Frank, MD Terence M. Davidson, MD Division of Head and Neck Surgery University of California, San Diego
HE AD& NECK
1990
183
TO THE EDITOR
Having read with interest H.A. Frank and T.M. Davidson’s article,’ we bring to your attention the following commentary: Workers in the field of oncology have learned that only an aggressive surgical treatment may ammeliorate the prognosis for most patients with head and neck cancer (excluding glottis carcinoma). Chemotherapy is beneficial for systemic malignancies, such a s Hodgkin’s disease or lymphomas, but has proved to be of limited efficacy in most head and neck carcinomas. Despite seemingly adequate primary therapy, a large number of patients experience recurrent disease, and salvage of these patients is usually a rare event. The cardinal question facing us under these circumstances is whether recurrence is the correct time to free the patient from the therapeutic burden or is an imperative for further struggle and extended use of drastic oncologic therapeutic measures. The humanist will state that the physician lacks the ability to guard the holy integrity of the soul and body of this very sick patient and must at this point leave the “wrestling ring” and discontinue his useless, tormenting medications. This philosophy of “leave him in peace” is not always completely free from economic and financial considerations, especially with regard to medical insurance companies and interested medical investors. Others, on the contrary, may think that every measure, even extreme, should be undertaken to give the patient even the smallest chance. The latter group believes that physicians should make treatment decisions regardless of economic considerations. The patient generally lacks decision-making ability at this stage and usually depends on his physician for advice. He asks to be patronized and guided by his doctor in this labyrinthine pathway of pain and suffering. The trivial daily tasks and choices like eating, drinking, or clothing are no more a matter of personal decision but rather a hospital team’s decision. The patient is tired and exhausted easily. Is there a problem of overtreatment in the oncologic patient with recurrent disease?
182
Letters to the Editor
Although the percentage of “five-year survivors” has grown during the last decade, the problem of recurrence remains nearly without therapeutic response in most cases. It can be stated that the increased survival rate after concentrated treatment of the primary tumor is paralleled by an increasing number of recurrences. Recurrence usually requires a more thoughtful decision-making process than the initial treatment, as surgery is more deformative, the physiological conditions are poorer, and cure is seldom encountered. In October 1988, during a conference of the Israel Society of Oto-Laryngology, the problem of the “overtreated patient with head and neck carcinoma” was brought up for discussion. We presented our results in two groups of patients with cancers of the larynx, oral cavity, hypopharynx, and sinuses with similar TNM staging. Both groups had undergone multiple ablative operations, followed by chemotherapy, irradiation, and plastic surgery. In one group, patients died within 10 to 30 months, with inumerable episodes of local recurrence, long hospitalizations, physical pain, and psychological torture. The patients in the other group experienced similar lengths of survival but were hospitalized for only short intervals, with a fair quality of life. Is modern medicine developing the syndrome of the “overtreated incurable patient?“ The subject is heavily in dispute and raises philosophical, medical, ethical and socioeconomic questions, as therapy for recurrent cancer is associated with considerable uncertainity. Disappointment plagues us, leading us to sometimes abandon the patient to suffer his last long months with misery. Experience as reported in the current medical literature is mostly irrelevant and provides few guidelines. The extreme variations in survival rates offer an element of hope, and I often feel morally obligated to plan and perform a therapeutic regimen for the incurable patient. I conclude with the following: (1)In our series, radiation or cytotoxic therapy following repeated surgery a t the primary site was not successful in controlling the recurrent disease. (2) No patient with recurrent disease remained alive for more than 10 to
HEAD & NECK
March/April 1990
30 months, although some maintained a fairly good quality of life. (3) For extreme illnesses, extreme treatments are most fitting (Hippocrates’). (4) When the physician is unsuccessful in his therapeutic measures, he should try to understand the message of the incurable patient-If he wants to fight, fight with him; If he doesn’t, try to relieve his pain and torment. Y. Zohar, MD M. Strauss, MD Department of Otolaryngology and
Head-Neck Surgery Hasharon Hospital Petach-Tiqwa, Israel
1. Frank HA, Davidson TM: Ethical dilemmas in head and neck cancer. Head Neck 11:22-26,1989. 2. Goepfert H: Are we making any progress? Arch Otoltzryngo1 110562,1984. REPLY:
The comments by Drs. Zohar and Strauss raise a number of issues that were addressed in part in our article. These are: 1. Is recurrence of cancer after appropriate primary treatment the time to consider withholding further treatment? We believe that whether to treat and how to treat should be thoughtfully considered and thoroughly discussed with the patient both initially and a t the discovery of recurrence. The possibility, the probability, and the significance of recurrence should be part of the initial discussion. This allows the patient to correlate this information with his or her goals and values in order to reach a decision in collaboration with the physician on how to proceed with treatment in the best interest of the patient. 2. To what extent should and do economic considerations enter into treatment decisions? Formerly, consensus was that economic aspects had no place in treatment decisions; however, this is now a controversial area. It appears to us that patients do on occasion appropriately decline expensive therapy with limited chance of success out of concern for impoverishing family members they will leave behind. That is their decision, and we believe it should be honored. When economic restraints are pressed on the decision process by public officials, insurance companies, or the administrators of hospitals and HMOs, we believe the physician should be the patient’s advocate. This is often difficult because such advocacy may place the physician in jeopardy with the institution in which he or she works, thus creating a conflict of interest. We are all coming to recognize that there are finite limits to the total quantity of medical care that society can afford and that these resources are not equitably distributed amongst all persons needing medical care. If economic restraints are to be placed on treatment decisions, we believe these should be made a t the soci-
Letters to the Editor
etal level and should apply to everyone. Individual physicians should not make these decisions with respect to individual patients. 3. To what extent do patients lack the ability to make informed decisions about their treatment? To what extent should physicians decide for them? Current consensus, supported by current law in the United States, is that, except in emergency situations requiring immediate decisions and actions, most patients can and do make appropriate decisions when properly informed. Information requires continuing dialogue as we pointed out in our paper. In head and neck cancer, there is clearly time to reach such decisions if the process is begun at first contact between doctor and patient. We believe it is rarely, if ever, necessary or appropriate for a physician to make decisions without collaboration with the patient or a suitable surrogate. 4. Is there a problem of overtreatment in the cancer patient with (and without) recurrent disease? How does one balance increased length of survival against decreased quality of life? We believe there is indeed overtreatment, perhaps frequently. This occurs for the reasons we discussed in our article: economic and academic interests of the physician; personal fear and lack of acceptance of death; evaluation of the balance between longevity and quality of life which differs from the patient’s; and religious beliefs. In each individual case “overtreatment” and “undertreatment” are difficult to define. This definition must be approached through consideration of the patient’s goals and values. 5. Are we morally obligated to pursue cure in the face of minimal hope of success? We believe the answer is no, if to do so is not in the patient’s best interest as defined by the patient. 6. Do physicians abandon patients when cure is impossible? Unfortunately, the answer is yes. Physicians sometimes feel inadequate or guilty if they fail to cure. Physicians who have not accepted their own inevitable death fear it and avoid dying patients. Physicians are educated and trained in curative medicine. They are often poorly trained in supportive medicine for patients with chronic and terminal illness. As a result, they feel uncomfortable and inadequate when called upon to offer comfort care and all too often back away from it. The result is psychological if not physical abandonment of dying patients. There is an oft-quoted aphorism from 15th century France: “To cure sometimes; to relieve often; to comfort always- that is the physician’s role.” We thank the commentators for giving us the opportunity to discuss the questions they raised. Hugh A. Frank, MD Terence M. Davidson, MD Division of Head and Neck Surgery University of California, San Diego
HE AD& NECK
1990
183
