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Let’s have honest conversations about cancer

Rather than focusing on the ‘magic bullets’ of new drugs, we should be talking to people with cancer about how to handle their condition

Rather than focusing on the ‘magic bullets’ of new drugs, we should be talking to people with cancer about how to handle their condition


Picture: Alamy

I last wrote a column for this journal more than five years ago. Then I became a medical director and found I didn’t have the time. Having now stepped down from that role, I can reflect on how things have changed in the intervening period.

Generally, things are worse. However, it might be argued that there has been at least one positive change in oncology with the Cancer Drugs Fund (CDF) enabling speedier access to anti-cancer drugs, particularly new immunotherapy agents which have exploded onto the scene recently.

However, I believe the CDF is still all about expediting the use of drugs which are either unproven or too expensive to be made available routinely. This fast-tracking must be good though, surely? The public and the media seem to think so, but are we conveniently deceiving our patients?

‘In many instances not only do the drugs work less well, but the side effects can be severe and debilitating’

Recently, I asked a couple of oncology trainee doctors what they thought the benefits were from CDF drugs. ‘How long on average does a CDF drug extend a patient’s life?’, I asked. One said five years, the other 18 months. The evidence suggests they are extremely optimistic.

Researchers (Aggarwal et al 2017) looked at 29 drugs that had been approved for use through the CDF in 2015 for 47 specific cancer indications and analysed them for effectiveness. They concluded that the ‘majority of CDF-approved indications were based on studies that reported minimal to no benefit in survival’. They found that only 18/47 of the uses were supported by clinical trials showing overall survival benefit — the median of which was 3.2 months, but benefits ranged from 15.7 to only 1.4 months.

Downsides

If less than 40% CDF drugs extend survival, and only by about three months on average, yet some doctors think the benefit can be as much as years, then what do our patients understand?

And what about the downsides? Immunotherapy drugs are the latest magic bullet, and there is no doubt that, in some cases, results can be dramatic. But in many instances not only do the drugs work less well, but the side effects can be severe and debilitating. Because the drugs are new, there is little experience in managing them and often the patients have to be admitted.

One day when I was on call recently, there were 11 admissions to the acute cancer ward, of which nine were directly due to complications resulting from immunotherapy.

People want these drugs and get upset by any perceived difficulties in receiving them, but how well informed are their treatment choices?

‘One day when I was on call recently, there were 11 admissions to the acute cancer ward, of which nine were directly due to complications resulting from immunotherapy’

What patients with incurable cancer need are honest conversations about their diseases, their treatment options, and perhaps most importantly, about what they want from their last months of life. I suggest that for anyone working with such patients, American surgeon Atul Gawande’s marvellous book Being Mortal is a must read. He explains the concept of structured conversations between clinicians and patients with ‘serious illnesses’ to allow people to make an informed choice about how they want to live their final months, so their care can be tailored accordingly.

Informed views

The Serious Illness Care Programme UK is now working with Dr Gawande’s team in bringing this approach to this country.

It has been introduced at the Clatterbridge Cancer Centre and has been embraced by patients and their clinical teams. Specialist nurses are especially enthusiastic about this opportunity for patients’ informed views to be used to plan their treatment (or, indeed their non-treatment).  

At Clatterbridge, nurses are now being trained to undertake these conversations, and if you or your centre would like more information on this project, please let me know.


References


About the author

Peter Kirkbride is national lead for the Serious Illness Care Programme UK, Clatterbridge Cancer Centre NHS Foundation Trust, England

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