First, Do Nothing

(From the New York Times)

The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.

The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.

What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?

Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.

I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.