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Originally published as JCO Early Release 10.1200/JCO.2003.05.082 on July 21 2003 © 2003 American Society for Clinical Oncology
Paris and New York: More in Common Than You Think!University of Vermont College of Medicine, Vermont Cancer Center, Burlington, VT CAN FIFTY million Frenchmen be wrong? Probably not! In this issue of the Journal of Clinical Oncology, Extermann et al1 describe their findings from a study comparing the willingness of older French and American patients to receive cancer chemotherapy.1 They did this to test their perception that European cancer patients are less likely to accept chemotherapy than Americans. Their focus on older patients is both timely and important; cancer is a disease of aging, and older patients are commonly under-treated. By 2030, 20% of Americans will be 65 years old or older.2 Moreover, the median survival estimate for healthy men and women who reach the age of 70 is 82 and 86 years, and for age 80, 87 and 89 years, respectively.3 Chemotherapy can cure acute leukemia, moderate and high grade lymphomas, testis tumors, and ovarian cancer in some patients. In conjunction with surgery and radiation, chemotherapy can prolong survival in patients with head and neck, lung, esophageal, gastric, rectal, and cervical cancer. In the adjuvant setting, chemotherapy improves survival in breast and colon cancer. Even for patients with metastases, chemotherapy can improve quality of life, diminish symptoms resulting from metastases, and prolong survival. Data consistently show that healthy older patients with cancer tolerate standard chemotherapy regimens as well as younger patients,4,5 which is why this study from Extermann et al is so important; we should have the ability to make life longer and likely better for older patients with cancer, regardless of geography. Between 1999 and 2000, Extermann et al sent anonymous questionnaires to 320 French and American outpatients 70 to 95 years of age; 61% responded, including 29% who were 80 and older. Ninety-eight patients had cancer (62 American and 36 French patients), and 97 control subjects did not have cancer (43 American and 54 French patients). The cancer patients were both seen at major centers: the Moffitt Cancer Center, in Florida, and the Centre Léon-Bérard, in Lyon, France. The consecutive sample of cancer patients included those with hematologic and solid tumors, and it included all stages and pathologic types. Fifty percent to 60 percent of American patients and control subjects rated their general health as good, compared to about 30% of French patients and control subjects. Participants were asked to review two different scenarios describing "strong" and "mild" chemotherapy regimens. Patients and control subjects were then asked to define the minimum benefit for which they would accept chemotherapy, including curing the cancer, prolonging survival, and reducing symptoms. American and French cancer patients had similar acceptance rates for strong chemotherapy (a platinum/taxane regimen) and mild chemotherapy (a weekly vinorelbine regimen), but French noncancer patients were significantly less likely to accept any chemotherapy, strong or mild. Although the range was wide, both French and American cancer patients averaged about 70% as their threshold for accepting either strong or mild chemotherapy as a potentially curative treatment. For prolongation of survival, the minimal threshold for both French and American cancer patients accepting chemotherapy treatment averaged about 20 months. About 70% of both cancer patient groups would have accepted chemotherapy to reduce symptoms, but fewer French noncancer patients would accept strong chemotherapy to improve their chances for cure, compared to American noncancer patients (52% v 68%, respectively). For mild chemotherapy, both French and American patients and controls gave similar responses to these "trade-off" questions. Are there cultural differences among French and American patients and physicians that relate to medical care? Western European and American cultures are thought to share a similar bioethical construct: a liberal, rights-based model stressing patient autonomy and the right to override medical recommendations, even when the patient’s mental capacity is in doubt.6 Nevertheless, there are probably important cultural differences between American, French, and other Western European patients and physicians, and these cultural differences may play a role in what and how different cancer treatments are offered. Eisinger et al suggested that cultural differences between French and American patients and physicians led to different clinical recommendations for women with increased risk of breast and ovarian cancer.7 The difference in recommendations suggested that French physicians were more likely to be resistant to patient autonomy in making medical decisions than American physicians and that individuals in the United States are urged to assume greater responsibility for their own health. These data are important, because in numerous studies, the physician’s recommendation is the most important factor in patients accepting treatment, especially older patients. In Western Europe and the US, the majority of patients desire precise information—whether good or bad—concerning their cancer diagnoses, and they allocate the major role in treatment decisions to their physicians.8 In addition, good communication skills are greatly appreciated by most patients, and patients place these skills high on their list of priorities for care. In the US, and almost certainly in Western Europe, ageism represents a cultural bias that commonly results in the under-treatment of older patients with cancer. In one study that used hypothetical treatment vignettes in US cancer patients, there was no effect of either age or stage on the acceptance of chemotherapy for cure or prolongation of survival, but older patients were less likely than younger patients to trade prolonged survival for current quality of life.9 Similar findings were noted in a Cancer and Leukemia Group B trial exploring the barriers to participation of older patients with breast cancer in clinical trials.10 Even after a multivariate analysis of major socio-demographic variables, age alone was the single significant independent risk factor for not being offered a clinical trial; however, a similar percentage of older and younger patients (about 50%) accepted trials participation when a trial was offered. Extermann’s data are provocative in suggesting that patients may frequently overestimate the potential value of chemotherapy as a curative treatment, an observation of great importance to medical oncologists. Although the patients in this study had different types and stages of cancer, it appears that they knew little about the potential for chemotherapy treatment to cure their cancer, prolong their survival, or relieve their symptoms. For those patients with a cancer curable with chemotherapy alone and for those with early breast or colorectal cancer who are candidates for adjuvant chemotherapy, physicians should make certain that the patient’s knowledge concerning the potential benefits of chemotherapy as well as its risks is accurate. Although French and American noncancer patients were somewhat different in their acceptance of chemotherapy, the differences were modest for the most part; when faced with a cancer diagnosis and the chance for cure, prolonged survival, or symptom control with chemotherapy, most patients accepted treatment.11 In my experience, this is also true for physicians who become cancer patients. Regardless of cultural differences, the major role of physicians and nurses everywhere is to provide the best care possible for their patients. We must clearly inform all our patients with cancer about the benefits and risks of treatment and make sure that all our patients clearly understand the treatment options available to them. Whether in Paris or New York, patients with cancer should be offered appropriate therapies, regardless of age. REFERENCES
1. Extermann M, Albran G, Chen H, et al: Are older French patients as willing as older American patients to undertake chemotherapy? J Clin Oncol 21:3214–3219, 2003 2. Yancik R, Ries LA: Aging and cancer in America: Demographic and epidemiologic perspectives. Hematol Oncol Clin North Am 14:17–23, 2000[CrossRef][Medline]
3. Walter LC, Covinsky KE: Cancer screening in elderly patients: A framework for individualized decision making. JAMA 285:2750–2756, 2001
4. Christman K, Muss HB, Case LD, et al: Chemotherapy of metastatic breast cancer in the elderly: The Piedmont Oncology Association experience. JAMA 268:57–62, 1992 5. Sargent DJ, Goldberg RM, Jacobsen SD, et al: Adjuvant chemotherpapy for colon cancer inelderrly patients: A pooled analysis of 3,351 patients. N Engl J Med 2001 (in press) 6. Dickenson DL: Cross-cultural issues in European bioethics. Bioethics 13:249–255, 1999[CrossRef][Medline] 7. Eisinger F, Geller G, Burke W, et al: Cultural basis for differences between US and French clinical recommendations for women at increased risk of breast and ovarian cancer. Lancet 353:919, 1999[CrossRef][Medline] 8. Aaronson NK: Assessing the quality of life of patients with cancer: East meets west. Eur J Cancer 34:767–769, 1998[CrossRef][Medline]
9. Yellen SB, Cella DF, Leslie WT: Age and clinical decision making in oncology patients. J Natl Cancer Inst 86:1766–1770, 1994
10. Kemeny M, Muss HB, Kornblith AB, et al: Barriers to participation of older women with breast cancer in clinical trials. J Clin Oncol 21:2268–2275, 2003
11. Slevin ML, Stubbs L, Plant HJ, et al: Attitudes to chemotherapy: Comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 300:1458–1460, 1990
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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