When Less Cancer Care is More

"Do-Everything" Approach to Cancer Care is Becoming Outmoded

The times they are a changing. And, at least this time, that can be a good thing. For years, the standard approach to treating a new cancer has been to throw everything possible at it. As an example, consider the history of breast cancer surgery. For a very long time, the only offered operation was a total mastectomy; this meant taking not only the breast, but all the underlying muscles. Women were left concave, very disfigured and often lost some function. Gradually the standard of care evolved to a simple mastectomy, taking only breast tissue, and then often to a wide excision or lumpectomy. Through the years, the do-everything approach has often meant surgery and radiation and chemotherapy and maybe some kind of ongoing oral therapy for years. Sometimes this is necessary and sometimes this tactic is exactly what a patient wants. But sometimes it is not.

As doctors learn more about the biology of cancer, the specifics of a particular cancer cell, they are learning that one size does not fit all, and that sometimes less treatment is equally effective. The Washington Post recently published an excellent article about this trend, and here is a quote:

"Increasingly, however, strong evidence for de-escalation is spurring cultural and medical practice shifts. A landmark clinical trial published in June found that more than two-thirds of women with early-stage breast cancer can safely avoid chemotherapy. Men with early-stage, low-risk prostate cancer are rapidly embracing “active surveillance” over surgery — and avoiding possible surgical complications such as incontinence and sexual dysfunction. And throat cancer caused by human papilloma virus, doctors now know, is different from other types of the disease, allowing a cutback in a brutal treatment regimen and reducing the risk of potentially devastating disfigurement."

Not all urologic cancer surgeons are equally open to the active surveillance approach for prostate cancer. I'm proud to say that the Prostate Cancer Program at the BIDMC Cancer Center has been a pioneer in this approach.

All of us would prefer to avoid disfigurement or major complications if we know that we are doing the right thing for our cancer treatment. This often becomes a discussion and a decision that is both intellectually and emotionally challenging. The thinking part can be addressed with questions to your doctor, reading on your own, and careful consideration of the choices. The feelings part can be harder.

We all remember the absolute panic we felt when we first heard the cancer diagnosis. Almost everyone’s immediate reaction is to do everything and anything to stay alive. We don’t quite beg our doctors for more drugs, but I have heard people say that they asked if more body parts could be removed while the surgeon was at it. When chemotherapy is completed, we often are very afraid of what may happen as being on the drugs feels safer. Women with ER positive breast cancers, for example, may stay on oral hormone/estrogen-blocker medications for years. Some women insist on continuing even when their oncologist eventually, after five or ten or more years, thinks it is time to stop. I am currently working with a woman who has recently been diagnosed with a second, more serious, cancer, but who insists on staying with the breast cancer medication that she began ten years ago.

There is no easy answer about how to handle these fears. It is important to acknowledge them and to try to speak honestly about your feelings. If talking with your doctor does not help you settle down, it might be wise to talk with an oncology social worker. Your feelings are your feeling; you are entitled to them. There is an old adage that the goal is to manage your feelings rather than having them manage you. This is almost always possible although it may take some work and some time. Making the best treatment decision is important, and you deserve whatever helps you get there.