Gray Matter

Rebecca Bechhold, MD

Oncologists deliver news-good and bad-on a daily basis. It is, for me, the most challenging and rewarding part of my job. Just as it is thrilling to share evidence of excellent response to treatment or ongoing states of no evidence of disease, it is heartbreaking-no, devastating-to have to inform patients of tumor progression or recurrence. Even those two scenarios are pretty straightforward; what is confounding to me is the scan that looks “pretty much unchanged” or shows good response in most areas but “may have new lesions” in other areas. I need definitive evidence from my radiologists: measure, describe in aching detail, tell me exactly what you see. Obviously, I want cold hard data to make treatment decisions, and sometimes the data is, well, fuzzy. We all scrutinize the images, looking for any favorable change.

What do we do with that muddled, gray area of not quite better but not a lot worse? Patients may be clinically doing great but they deserve to have the same information that we have as they tolerate the many side effects-physical, psychological, and financial-of their antineoplastic agents. I find myself wanting to stay the course when the patient is otherwise doing well and the imaging does not provide profound changes to push me to pursue another line of palliative therapy.

Laurent Knoops, MD, PhD, and Philippe Bastin, MD, recently published an article entitled “Escalation of Commitment in Decisions Near the End of Life” in JAMA Oncology. In it, they address why doctors and patients continue with increasingly ineffective therapy. Their examples mostly referenced end-stage hematologic malignancies, so I am appropriating some of their ideas to solid tumor cases as well. To paraphrase, doctors are reluctant to change or stop treatment in the face of failure to respond because we (and the patient) are influenced by “escalation of commitment.” They state, “If treatment response is poor, physicians or patients tend at times to rationalize their initial decision by continuing therapy or switching to another treatment option, in line with the primary decisional process.” It is true that once we commit we have a hard time stopping or changing therapy even when it is clearly not working.

I saw a patient today; he is 84 but looks younger, very distinguished, handsome, and a meticulous dresser. He has had stage IV colon cancer since I met him over a year ago. He has been through two lines of therapy with no real response other than recurrent marrow suppression and mouth sores. I finally convinced him to take a drug holiday over Christmas to enjoy the time with his family. I had adjusted the drug dose many times but I don’t think he was getting much from the chemotherapy other than the psychological benefit and the socialization (he adores coming in to see me). He felt much better today after a break, and his imaging shows minimal growth in his tumor over the last 6 months. I want to follow him off therapy. It took a lot of convincing, since he wrongly equates getting chemotherapy with fighting and thus living longer. I told him that I didn’t think he would be any worse if he had not taken the last 6 months of treatment-it was practically homeopathic. I am certain that some tumors just grow too slowly to be influenced by chemotherapy. By the time he left, he was actually happy and knew he was going to enjoy feeling better for now. He will still see me regularly, which gives him a feeling of security.

Of course there are many times when the situation is not that clear to me and I continue the maintenance therapy with “minimal” changes on the CT and a patient who feels great. But am I correct or just too committed to my treatment to make a change? I explain it to the patient, but I am sure my tone implies my preference.

What do you do when the evidence for response is mixed? How do you discuss it with the patient? Is there a right or wrong path? If only oncology decision making was as easy and clear-cut as those NCCN guidelines and charts make it look.