Winter 2013 
 

George J. Weiner, MD, is director of the Holden Comprehensive Cancer Center at the University of Iowa and vice president/president-elect of the Association of American Cancer Institutes.


Commentary Overview

* The goal of medical education, research and care is not only to extend patients' lives, but to enhance their quality of life.

* Some patients receive therapy that is unlikely to help, yet is costly with respect to both quality of life and actual dollars.

* To help assure that every patient gets the best possible cancer care, academic cancer centers must take the lead in defining new approaches to education, research and patient care.

About AACI Commentary

As part of AACI's efforts to feature the work and views of its member centers, AACI has launched AACI Commentary, a quarterly editorial series. Written by cancer center leaders, each edition will focus on a major issue of common interest to the nation's cancer centers.



More is Not Always Better

BY GEORGE J. WEINER, MD

My father was diagnosed with a widespread Adenocarcinoma of Unknown Primary several years ago when he was in his mid-80s. A short course of chemotherapy had a modest impact on the cancer, but the side effects of the therapy were significant, and he decided not to continue the chemotherapy. He enrolled in hospice, and other than a few short stays in the hospital, spent the remaining months of his life at home doing what he loved, surrounded by family. We had many discussions during that time about what therapies he should and should not take. I still miss him dearly, but am comforted to know I did what I could to assure he had the highest possible quality of life during his final months.

My advice to my father, and to my patients, is based on the knowledge that for some patients, intensive therapy with curative intent or a goal of significantly extending survival is appropriate. For others where cure is not possible and the likelihood of meaningful extension of life is limited, gentler therapy geared toward maintaining or improving quality of life can sometimes be a better choice.

Assuring every patient across the country gets the best possible cancer care is difficult. There is a growing demand for cancer care, treatments are increasingly complex, there are not enough well trained clinicians in the workforce, and costs of cancer care continue to rise. In addition, our current use of cancer care resources is out of balance. Some patients receive therapy that is unlikely to help, yet is costly with respect to both quality of life and actual dollars. Others do not have access to quality cancer care. The solution requires a fundamental change in our approach to cancer care. The Institute of Medicine (IOM) recently outlined the challenges in our cancer care delivery system, and how we might respond to them, in a report titled, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis."

The new course outlined in this report will not be easy but is desperately needed. Academic cancer centers must take the lead in charting this new course in each area of our tripartite mission of education, research and patient care.

Education
We need to improve our teaching of communication skills to the next generation of cancer clinicians so they can help patients and their families clearly understand the goals of a particular cancer therapy and what they can expect to gain (or lose) from that therapy. The decision not to use every possible cancer therapy for every patient should not be equated with giving up, rationing, or responding to "death panels." Instead, choices should be based on what is right for each patient. With better communication, patients will have more accurate expectations, and more patients may choose to do what my father did, and decide to focus on quality of life.

Research
Along with basic, clinical and population-based cancer research, we need to explore how cancer therapy impacts quality of life and conduct health services research exploring more effective and efficient approaches to delivering quality cancer care to the underserved.

Patient care
In addition to providing state-of-the-art, evidence-based anti-cancer therapy, we need to provide care focused on enhancing the quality of life. We also need closer collaborative efforts between academia and the community. Both academic and community cancer centers have an important role to play in the care of cancer patients. Moving forward, incentives need to be developed that encourage both academic and community cancer centers to do what they do best, not what results in greatest reimbursement in our current fee-for-service environment. In my father's case, cost did not play a role in our decision not to pursue some very expensive treatment options, but our decision not to go with those treatments did result in less expensive care.

During the last few months of his life, my father repeated one of his favorite maxims—"there always will be ten leading causes of death." I would like nothing more than to see cancer come off that Top Ten list and we will continue to strive for that day. However, doing so should not blind us to the fact that the goal of medical education, research, and care is not only to extend the lives of our patients but also to improve and enhance their quality of life. To achieve that goal, more is not always better.

An earlier version of this Commentary first appeared on Dr. Weiner's blog, Holden the Line on Cancer.


 
Representing 92 of the nation's premier academic and free-standing cancer research centers, the Association of American Cancer Institutes is dedicated to promoting leading research institutions' efforts to eradicate cancer through a comprehensive and multidisciplinary program of cancer research, treatment, patient care, prevention, education and community outreach.