If a study in the current issue of the New England Journal of Medicine was a report about a new treatment that extended the lives of patients with advanced lung cancer by almost 3 months, the crowds would be cheering. But it isn't a study of a new chemotherapy drug, targeted therapy or vaccine. And I doubt there are lots of cheers in the audience.
It's much simpler than an expensive, complicated new treatment for a devastating disease. It's about starting palliative care to help patients deal with the symptoms from their disease and its treatment early in the course of that disease leading to a dramatic improvement in survival in a cancer that is almost always fatal.
Non-small cell lung cancer is a killer for many people. Lung cancer is the leading cause of cancer death in this country, although the numbers are declining with the decrease in smoking, especially among men. But once diagnosed as having spread outside the primary area of the cancer, the outlook is grim and for most folks is less than one year.
That one year is difficult enough knowing that you have a fatal illness. But the treatments for the disease-and the disease itself-can be devastating. Those treatments may buy a couple of months, but there is no dramatic impact for most people and the inevitable outcome can't be avoided.
Couple that very sad fact with the other reality that we don't do much in this country to help people through the process. Dealing with pain, treatments, nausea, vomiting, weight loss-the common effects of cancer treatment and the illness-is very difficult under the best of circumstances. And these folks-since they have usually (but not always) been smokers for much of their lives-have other serious medical problems with their hearts and lungs which complicates the situation further.
Palliative care is designed to help people and their families address these symptoms, along with the other issues that come along with a diagnosis of a fatal cancer. How to make the right medical decision for the individual is one example. What about end-of-life care, and whether or not they want to be aggressively treated with chemotherapy and even resuscitated if they should stop breathing or their heart stop functioning? When is the best time to seek hospice care? What are the advantages and disadvantages of continuing chemotherapy in the face a relentless progression of the cancer?
These are some of the issues that palliative care teams-composed of doctors, nurses, social workers, dietitians and other professionals-can address with patient and families. In fact, according to the article, over 80% of large (greater than 300 bed) hospitals in this country have such teams. But unfortunately for the most part these teams don't get called in to help until very late-and maybe too late-in the course of the illness.
The study reported in the New England Journal addressed the question of whether or not calling in the palliative care team to help patients and their families early in the course of treatment made a difference compared to what usually is done, which frequently means a consultation when a patient is in great pain, severely depressed, or near the end of life.
The researchers found that by engaging the palliative care experts early on made a substantial difference in the quality of life of the patients.
Those patients who received early palliative care had a better quality of life, less depression, and most remarkably lived 2.7 months longer than those who had routine care (it is important to point out that all patients in the study, including those who received early palliative care and those who did not, were treated by the same group of doctors and had the same access to chemotherapy treatments). The net difference was 11.6 months for the palliative care patients, compared to 8.9 months median survival (that means half lived less and half lived more) for those patients not receiving the early palliative care intervention. This improvement occurred despite the fact that the palliative care patients had less aggressive care at the end of life.
If that degree of improvement in life expectancy was seen in a clinical trial looking at survival after treatment with a new chemotherapy drug, there would be applause all over the place. Instead, I fear that many physicians will just yawn and say something to the effect of "Here they go again with that pain stuff."
How did this simple, straightforward approach result in such a remarkable outcome? The answer is that no one is really certain.
Years ago, there was a genuine question as to whether or not chemotherapy made any benefit in the outlook for patients with non-small cell lung cancer that had spread through the body.
It took a number of years of research and clinical trials to come to the conclusion that chemotherapy did in fact improve survival for patients with this disease. It took more years to determine that we didn't have to throw every drug we knew worked in lung cancer at our patients in order to lengthen their days. Yet even though the treatments have been shown to have genuine value and increase survival, they come with a huge price in side effects and quality of life. And, we still remain hugely frustrated as patients, families and doctors at the lack of a true breakthrough in the treatment of metastatic lung cancer.
Now, along comes a study that says if we just paid a bit more attention to our patients' symptoms, offered them more support, answered their questions about their treatment options, and helped them plan for their near-term future and outcome by understanding their wishes and respecting their decisions, and give that care in addition to standard chemotherapy, then we could significantly improve and prolong their lives.
This is not an especially expensive approach to medical care, my friends.
The investment in palliative care certainly pales in comparison to the costs of the drugs we use in treating cancer, and lung cancer in particular. But the returns on that investment-at least according to this study and a recent exellent article in The New Yorker magazine by Atul Gawande--are obviously immense.
Maybe it's time to realize that with all of our powerful medicines and other treatments we still have one medicine that we don't utilize often enough, and that is genuine caring and support for someone in distress.
As a young physician years ago, I learned to never underestimate the impact of a healing hand, a willingness to listen and an opportunity to provide support and guidance. It can truly make a world of difference.
This study shows that rediscovering the value of what we used to do before we were able to do what we can do is a lesson well worth relearning.