This morning’s *New York Times* includes an article: “In Cancer Therapy,
There Is a Time to Treat and a Time to Let Go” by Jane Brody.

Here are some excerpts:

[begin excerpts]

Thirty years ago Forbes Hill of Brooklyn learned he had prostate cancer.
At age 50, with a young wife and a fear of the common side effects of
treatment — incontinence and impotence — he chose what oncologists call
“watchful waiting.” For 12 years, Mr. Hill was fine. Then in 1990 his
PSA count, a measure of cancer activity, began to rise, and he had
radiation therapy. That dropped the count to near zero. In 2000, with
the count up again, he chose hormone therapy, which worked for a while.

Three years ago, with his PSA level going through the roof, he learned
that the cancer had spread to his bones and liver. It was time for
chemotherapy, which Mr. Hill said he knew could not cure him but might
slow the cancer’s progress and prolong his life.

His oncologist was candid but not very specific. His doctor told him
that with advanced metastatic hormone-resistant cancer like his, 90
percent of patients die within five years no matter what the doctors do,
and about 10 percent survive six or more years.

“I took that kind of hard,” said Mr. Hill, an associate professor of
media studies at Queens College. “I always thought I would live to 90,
but I guess now I won’t.”

He has just started radiation to the brain, perhaps with infusions of an
experimental drug afterward. “I’ll try chemo for six months, but if it
gets too uncomfortable and inconvenient… ,” he said, trailing off.
“Having lived 80 years, I’ve done a lot. I don’t have reason to think
I’ve been badly treated by life.”

Mr. Hill seems ready for a time when treating his cancer is no longer
the right approach, replaced instead by a focus on preparing for the end
of his life.

But doctors who have studied patients like Mr. Hill say that often they
do not know when to say enough is enough. In a desperate effort to live
a month, a week, even a day longer, they choose to continue costly,
toxic treatments and deny themselves and their families the comfort care
that hospice can provide.

Tough Decisions

Specialists in ovarian cancer from University Hospitals Case Medical
Center in Cleveland described a study of 113 patients with ovarian
cancer in the journal Cancer in March.

“Patients with a shorter survival time,” they found, “had a trend toward
increased chemotherapy during their last three months of life and had
increased overall aggressiveness of care [but] did not have improvement
in survival.”

The team concluded, “Our findings suggest that in the presence of
rapidly progressive disease, aggressive care measures like new
chemotherapy regimens within the last month of life and the
administration of chemotherapy within the last two weeks of life are not
associated with a survival benefit.”

With aggressive therapy, the majority of the women in the study who died
did so without the benefit of hospice.

Dr. Thomas J. Smith, an oncologist and palliative care specialist at the
Massey Cancer Center of Virginia Commonwealth University, said in an
interview that patients needed to understand the tradeoffs of treatment.

“Palliative chemotherapy, which is what most oncologists do, is meant to
shrink cancer and improve the quality and quantity of life for as long
as possible without making patients too sick in the bargain,” he said.

The Cleveland team pointed out that the treatment goal can, and should,
change. “There is a difference between palliative chemotherapy
administered early in the trajectory of disease and near the end of
life,” the researchers wrote. “The goal of end-of-life care should be to
avoid interventions, such as cytotoxic chemotherapy, that are likely to
decrease the quality of life while failing to increase survival.”

In fact, those who choose hospice over aggressive treatment often live
longer and with less discomfort because the ill effects of chemotherapy
can hasten death, Dr. Smith wrote in a review of the role of
chemotherapy at the end of life, published in June in The Journal of the
American Medical Association.

Some patients are just unwilling to acknowledge that nothing can save
them, and want toxic treatment even if it means only one more day of life.

And sometimes patients are reluctant to relinquish treatment because
they are terribly afraid of dying, of being alone cut off from care, Dr.
Smith said in the interview. Patients may fear, with some justification,
that if treatment stops the doctor will abandon them.

It is not only patients and their families who may insist on pursuing
active treatment to the bitter end. Sometimes, doctors subtly or overtly
encourage it.

<snip>

For those who are confined to a bed or a chair for half or more of the
day, “it is time to think long and hard about continuing treatment,” he
said. “It’s time to have an extensive discussion with patients about
their goals and the risks and benefits of chemotherapy.”

He suggested that doctors “put everything in writing — here’s what you
have, what we can do for it, what will happen with treatment and without
it — so that everyone is on the same page,” eliminating the risk that
wishful thinking colors what patients hear.

When faced with a patient who says, “I’ll do anything to live two
minutes longer,” Dr. Smith said the doctor should ask: “What is your
understanding of your illness? What would you like to do with the time
remaining?”

For most people, he added, the time left would be far better spent
putting their affairs in order, preparing their funeral or memorial
service, repairing damaged relationships, leaving lasting legacies and
saying their goodbyes.

[end excerpts]

The article is online at:
<http://www.nytimes.com/2008/08/19/health/19brod.html>.

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