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Editorial Volume 9 Issue 1
Specific Therapy or Best Supportive Care: A Dilemma
Hajj Adel Anis
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Cedars - Jebel Ali International Hospital, UAE
Correspondence: Hajj Adel Anis, Medical Oncologist at Cedars - Jebel Ali International Hospital, 9370 Rue Lajeunesse, Montreal, UAE, Tel 438-992-5516
Received: October 22, 2014 | Published: January 31, 2018
Citation: Anis HA (2018) Specific Therapy or Best Supportive Care: A Dilemma. J Cancer Prev Curr Res 9(1): 00315. DOI: 10.15406/jcpcr.2018.09.00315
Introduction
The sign of a mature oncologist knows when NOT to treat a particular patient. It is often an intuitive feeling, but the question is: do we have any tools that allow us making decisions in palliative cancer treatment with a stronger evidence base?
Palliative chemotherapy aims at maintaining or improving quality of life. Survival gains, if present, are modest. Best supportive care is the alternative option and aims at enhancing quality of life by the relief of symptoms once they occur. At the same time, limited survival gain, whatever, may be important from the patient’s perspective. Knowledge of the factors upon which patient’s preferences are to be based, is necessary in guiding the patient and the physician through the decision-making process.
Factors influencing cancer patients’ treatment choice
“Richards et al” distinguished four factors: 1-Patients’ attitudes and beliefs 2-Doctors’ attitudes 3-The way information is presented 4-The nature of the risk and benefit involved in the different treatment options
Patients’ attitudes and beliefs are thought to be based on previous experience. Doctors’ attitudes are influenced by what they think is the aim of the therapy: relief of symptoms, life prolongation and psychological support. Studies have looked at the influence of the way information is presented to patients; it was found that the formulation of information impacts patients’ choices (McQuellon et al; Yellen and Cella; Flood et al; Mazur and Hickam; O’Connor). However, the relative value attached to treatment options in palliative care, such as chemotherapy and supportive care, is less well documented.
How to explain and to deal with the emotions of patients refusing treatment
It is a real dilemma when patients refuse a treatment or decide for a treatment against physician’s recommendation. This issue was discussed at the: “Interdisciplinary Conference on Supportive Care, Hospice and Palliative Medicine, Sponsored by the University of Texas MD Anderson Cancer Center”.
“Although refusal is a basic human right, as is asking for treatment the physician may consider futile, physicians can resolve the problem a big percentage of the time” said Eduardo Bruera, MD, Chair and Professor in MD Anderson’s Department of Palliative Care and Rehabilitation Medicine; “Patients have to make decisions under extremely difficult circumstances, particularly when they are getting to the level of having a very advanced cancer. The emotional component drives a lot of the decision-making. Cognitive aspects (where my cancer is, what my odds are) are only part of patient’s decision-making, so we need to understand their emotions” he added.
Refusal of treatment may be the result of a feeling of exhaustion, depression, or not to be a burden to the family. “Always remember, decisions are being made in the context of not feeling well” Professor Bruera said again. From the other side, negative emotional patients’ attitudes, may affect the treating physician and the team who can feel hit by the denial of the advantage of their recommendations. This contrariety is to be resolved. The first step “find out exactly what the patient wants and figure out why they want this…” Second, if depression and exhaustion are the cause, “depression management can help” he said. Finally, what is the family’s influence?
“Decision making does not follow specific pathways or clinical guidelines” he continued. “Clinical care guidelines are useless in situations that call for personalized care. What we are managing is the person…the decision has nothing to do with the disease or the stage…”
Conclusion
The information process should address the limited survival benefit of palliative chemotherapy and the possibility of best supportive care. It is obvious that, both, physician and patient have a natural tendency to “do something” and the available treatment options are equivalent in palliative treatment. Thus, the need for a model of shared decision-making, in which different treatment options are explained, is essential.
Conflicts of interest
None.
Acknowledgments
None.
Funding
None.
©2018 Anis. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.