|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
© 2003 American Society for Clinical Oncology
Communicating the Value of Adjuvant ChemotherapyFrom the Division of Hematology-Oncology, Department of Internal Medicine, Maricopa County Medical Center, Phoenix, AZ. Address reprint requests to Guru Sonpavde, MD, Hematology-Oncology Clinic, Comprehensive Health Center, Maricopa County Medical Center, 2525 East Roosevelt St, Phoenix, AZ 85008; email: gsonpavde{at}att.net. THE CASE I walk into the patient examination room with the medical resident, who previously had completed a history and physical examination on Ms K, a new patient to our Oncology Clinic at the county hospital. Her medical records indicate that she is a 68-year-old woman who was diagnosed with breast cancer 3 months ago. At diagnosis, she elected to have a modified radical mastectomy. The final pathology revealed a 2-cm invasive ductal cancer with all 10 axillary lymph nodes negative for cancer. The tumor stained positive for estrogen and progesterone receptors. She was then referred to a medical oncologist to discuss adjuvant therapy, with a decision being made to administer four cycles of adjuvant chemotherapy with a combination of doxorubicin and cyclophosphamide. She has already received two cycles of this chemotherapy and now has had to change her oncologist midstream because of insurance issues. Her medical records indicate that she suffered from pneumonia after her second cycle of chemotherapy, causing her to be admitted to a local hospital for 5 days. Our conversation proceeded as follows: Dr. GS: Hello, Ms K, I’m the staff oncologist. How are you doing? Ms K: Hi Doc! I’m just hanging in there right now. The pneumonia really put me down, but I am feeling better now. Dr. GS: As I understand it, you were scheduled to receive four treatments of chemotherapy and have finished two treatments so far. If you are ready, we can go ahead and get you started on the last two planned treatments. We can reduce the dose by 20% to decrease the chance of another infection. Ms K: I am not sure I want more chemotherapy after what happened after the last treatment. In your opinion, Doc, do you think I really need the chemotherapy? Dr. GS: To address your question, I can share with you some information from a computer program that is available to try to illustrate the perceived benefits of adjuvant chemotherapy for a patient in your situation. Before doing this, let me ask you if it is acceptable for me to provide you with your estimates of prognosis with and without drug therapy. Ms K: Yes, please do. I think that this would help me. Dr. GS: To do this, I can put four factors about your case into a computer program developed by doctors at the Mayo Clinic. These factors are (1) that you are older than 50 years; (2) that your tumor size was between 1.1 and 2.0 cm; (3) that your lymph nodes did not reveal any evidence of any cancer in them; and (4) that your tumor was estrogen receptor–positive.1 After providing this information to the computer program, it gives estimates about how many women with these characteristics would not have any evidence of cancer recurrence 10 years after diagnosis. The answers it provides in your situation are that 81 of 100 women would not be expected to have recurrent breast cancer with just the surgery that you had. Administration of tamoxifen for 5 years increases this to 85 women, whereas administration of four cycles of the chemotherapy that you are receiving is estimated to increase this number to 87 women. Ms K: So, this chemotherapy that I am getting is only improving my odds by 2%? I was never told what you are telling me now. To me, the 2% improvement in chance of cure with chemotherapy does not appear to be worth the side effects. If I had known these facts back then, I would not have agreed to take chemotherapy. In your experience, Doc, what are the side effects of chemotherapy and tamoxifen? Dr. GS: Chemotherapy is generally well tolerated over 2 to 3 months. However, there is a chance for significant nausea and vomiting, and this may lead to dehydration that may necessitate intravenous fluids in a few patients.2 There is a chance of infections, like the pneumonia you had, in approximately 5% to 10% of patients.2 In patients who receive four treatments of doxorubicin-containing chemotherapy, there is a less than 1% chance of weakening of the heart muscle that can lead to heart failure.3 Hair loss occurs in virtually all patients, but the hair grows back a few weeks after the last dose of chemotherapy. Approximately 1% to 2% of patients will develop significant inflammation in the mouth and/or diarrhea.2 Although it is very unusual with just four doses of chemotherapy, there is a less than 1% risk of acute leukemia many years later.2 This type of leukemia is resistant to current chemotherapy regimens and is usually lethal. Last, fatigue is common, and there are suggestions that chemotherapy might cause some trouble with mental function. Tamoxifen, on the other hand, is remarkably well tolerated. The most common side effect is an increased onset of hot flashes, but there is treatment that can be prescribed to alleviate this toxicity. The most serious side effects with tamoxifen are a less than 1% increased chance of tumors in the uterus and a small similarly increased chance of getting blood clots.4 However, tumors in the uterus can usually be discovered early and generally are easily curable by surgery. Lastly, there is a small increased risk of cataracts. On the positive side, tamoxifen can retard the progression of osteoporosis and thus decrease bone fractures.5,6 Ms K: Now tell me this, Doc. If you were in my place, would you want to receive chemotherapy? Dr. GS: This is an individual value judgment, and what I decide may not be what someone else decides to do. Having said that, especially knowing the side effects you have had, I would agree with you that it would be reasonable to stop the chemotherapy. However, many, and maybe most, patients with your stage of cancer, in my experience, have opted to receive chemotherapy. Ms K: Dr. GS, this is a lot of information that I did not have. I am quite convinced now that I do not want any further chemotherapy. Dr. GS: Are you are agreeable to taking tamoxifen oral tablets? Ms K: Yes, that sounds reasonable. Dr. GS: I will then prescribe tamoxifen, 20-mg tablets, for you to take once a day. Tamoxifen is prescribed for a period of 5 years. I will see you every 2 to 3 months during the first year and we will then reduce the frequency of visits slowly. We will also obtain yearly mammograms to screen for new cancers in your remaining breast. You should also have a yearly pelvic exam. Ms K: Doc, thanks for spending the time to explain these things to me. Dr. GS: I’m just doing my job, Ms K. Do you have any other questions? Ms K: No, Doc. Thanks once again. Dr. GS: You are quite welcome, Ms. K. DO ONCOLOGISTS KNOW WHAT IS BEST FOR THEIR PATIENTS? This scenario has occurred, with modifications, several times at my clinic. All too often, oncologists are guilty of deciding what is best for the patient. This may be especially true in the arena of adjuvant chemotherapy. To the busy oncologist, presenting all the facts and building a case for adjuvant chemotherapy might be vastly more complicated and time consuming than telling the patient what he or she needs. The availability of the above-described program, however, can simplify this process. Exaggerating the benefits of chemotherapy also appears to be prevalent; for example, the patient is often told, "You need chemotherapy to cure your cancer." Furthermore, poor reimbursement for time makes a long discussion of the pros and cons of adjuvant chemotherapy in an individual patient distinctly unattractive to some oncologists. On the other hand, a handsome reimbursement for administering chemotherapy may be a powerful incentive for encouraging adjuvant chemotherapy. VALIDITY AND AVAILABILITY OF PROGNOSTIC PROGRAMS The Numeracy program is freely available for use at www.mhs.mayo.edu/adjuvant, whereas another, more detailed, prognostic program, entitled Adjuvant!, is also available (it can be ordered at www.adjuvantsite.com or at AdjuvantProgram{at}aol.com.) These relatively independently developed programs, details of which have been previously published in this journal, provide remarkably similar outcome data, serving to validate each of the tools.1,7 Both programs provide computer printouts that can detail individualized numeric information, and corresponding graphic illustrations for patients to review. A more in-depth description of the similarities of, and differences between, these two programs is available.8 GIVE THE PATIENT THE OPPORTUNITY TO MAKE AN INFORMED DECISION Clearly, adjuvant chemotherapy does benefit many breast cancer patients, but to varying degrees. The magnitude of benefit for an individual patient is a vital component of the discussion with the patient, assuming that a patient is willing to be told prognostic information (make sure to ask before providing such information). Ideally, the patient should be given the chance to make the decision about whether to receive adjuvant chemotherapy, using the information oncologists provide. Although some patients will want adjuvant chemotherapy for even a 1% improvement in cure rate, others may find a 5% to 10% absolute improvement in cure rate not worth the short-term side effects of chemotherapy.9 However, no matter what the relative benefit of adjuvant chemotherapy is, it behooves oncologists to participate in an honest discussion of the benefits and risks of chemotherapy in every individual patient and give the patient the chance to make the decision for, or against, adjuvant chemotherapy. Of note, a randomized study suggests that providing individualized written information results in more satisfied patients.10 "DOC, DO WHATEVER YOU THINK IS BEST FOR ME" All oncologists have faced patients that do not want to take responsibility for—or are simply not capable of, or are not interested in—making a decision in this situation. "Doc, do whatever you think is best for me," is a familiar refrain we hear from some patients, even after spending time educating them about the benefits and risks of adjuvant chemotherapy. In this situation, I personally imagine the patient to be a close friend or family member and make a decision on the basis of my bias for or against adjuvant chemotherapy. REFERENCES
1. Loprinzi CL, Thome SD: Understanding the utility of adjuvant therapy for primary breast cancer. J Clin Oncol 19:972–979, 2001
2. Fisher B, Anderson S, DeCillis A, et al: Further evaluation of intensified and increased total dose of cyclophosphamide for the treatment of primary breast cancer: Findings from the National Surgical Adjuvant Breast and Bowel Project B-25. J Clin Oncol 17:3374–3388, 1999
3. Lipshultz SE, Grenier MA, Colan SD: Doxorubicin-induced cardiomyopathy. N Engl J Med 340:653–655, 1999 4. Tamoxifen for early breast cancer: An overview of the randomized trials. Early Breast Cancer Trialists Collaborative Group. Lancet 351:1451–1467, 1998[CrossRef][Medline] 5. Love RR, Mazess RB, Barden HS, et al: Effects of tamoxifen on bone mineral density in post-menopausal women with breast cancer. N Engl J Med 326:852–856, 1992[Abstract]
6. Fisher B, Constantino JP, Wickerham DL, et al: Tamoxifen for prevention of breast cancer: Report of the National Surgical Adjuvant and Bowel Project P-1 study. J Natl Cancer Inst 90:1371–1388, 1998
7. Ravdin PM, Siminoff LA, Davis GJ, et al: Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 19:980–991, 2001 8. Loprinzi CL, Ravdin PM. Decision-making for patients with early breast cancer: Individualized decisions for and by patients and their physicians. J Cancer Care Network (in press). 9. Ravdin PM, Siminoff IA, Harvey JA: Survey of breast cancer patients concerning their knowledge and expectations of adjuvant therapy. J Clin Oncol 16:515–521, 1998[Abstract] 10. Ravdin PM, Siminoff L, Hewlett J, et al: Evaluation of impact of communication tool generated by the computer program, Adjuvant!, on patients with early breast cancer and their doctors. Proc Am Soc Clin Oncol 20:31a, 2001 (abstr 119) Submitted September 16, 2002; accepted November 22, 2002.
This article has been cited by other articles:
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
