A Very Narrow Line

What does a physician tell a newly diagnosed cancer patient? That is a vital question and paramount in the mind of every physician as cancer is diagnosed or treatment or lack thereof is recommended. If the physician is overly pessimistic or in some cases brutally frank without optimism, the life of the patient is ruined and the chances of recovery is eliminated if there is any truth to the belief that the patient’s attitude has a bearing on their recovery. If the physician is overly optimistic, the patient will not be prepared for an adverse outcome and will not put forth the necessary energy to help themselves. The line that must be trodden by the quality physician with the best interest of their patient at heart is very narrow and difficult.

Either extreme is by far the easiest from the doctor’s point of view. If they make an extremely negative prognosis and even add a time limit on life, they will either be proved right or will receive credit for miraculously saving their life. While it is a horrible situation for the patient and their family, it will end up rewarding for the physician. On the converse, if they are overly optimistic and make a falsely favorable prognosis, they will be a wonderful fellow, at least for the time being. Then they can let the future take care of itself. But they are denying the patient the right to fight for their life by denying them the knowledge of the severity of their situation.

I talked with a lady with a cancer that has current SEER statistics of less than a 50% chance of 5 year survival. I suggested that in addition to the state of the art treatments her physician is giving her, she consider attending a support group, which has been shown by clinical trials to extend patient’s lives. Her answer was why should she waste her time since her doctor said he would cure her! My feeling is maybe he will and maybe he won’t. Cancer is not a disease you have the luxury of looking back and saying, “I wish I would have.” The patient must do everything right the first time to improve their odds of success. Then they can have the luxury of looking back and trying to figure out which made it possible and which was not worth while.

Another woman called me for help in finding a psychiatrist. She could not tolerate the mental anguish she was going through with her cancer and had called her oncologist for referral to a psychiatrist. He stated she didn’t need one and that he was all the psychiatrist she needed. Can you picture that egotism! Think of the stress and effort it takes for a rational individual to ask for the help of a doctor to treat her mind and then to be rebuffed and told she doesn’t need it.

The line a physician treating cancer walks is precarious. Their goal must be to form a team with the patient as a member – the managing member. The manager can not make wise decisions without knowing all the facts. When they do know the situation, they make the decision and count on each member of the team, of which they are one, to make the plan work. If they are told they won’t survive, they are not included in the team. Equally, if they are told they will be cured and don’t worry about it, they are excluded from the team.

Every patient is different. Some are young, some are old. Some are healthy, some are sickly. Some have a strong desire to live, some don’t. If statistics say I had a year to live without treatment but 6 months of very harsh treatments had a 10% chance of curing me, what would I do? If I were 95, a might forgo treatments. If I were 59, I personally would go for them. Even with only a 10% chance of the treatments helping me, I personally believe the quality of life is better fighting to live than waiting to die. But I doubt if I were 95, I would still believe that, considering the hardships of treatment. But that is my decision based on my life and my situation, not my doctor’s.

With the full truth couched in optimism, the patient will be able to make the proper decision and then be able to cooperate with the physicians in order to have the plan come out with the most favorable results possible. The good oncologist, the one interested in successfully treating each patient, wants the patient as an active participant. That insures the best chance of success, even if the rewards have to be shared with others.