Dr Neel Bhuva, Senior Registrar in Clinical Oncology, London, UK, explains the background to his longer research article published in the September/October European Journal of Palliative Care.
Modern medicine continues to work its miracles in, thankfully, an ever-increasing number of patients… but sometimes we forget that there is an actual patient in front of us. This may sound a bit funny to the person on the street, but it’s true. There is such a wealth of potential options available that doctors can easily get carried away deliberating over which treatment we can give rather than deciding what treatments we should give.
As a clinical oncologist in London, I see a wide variety of patients in my everyday practice; from those that we can cure to those that we unfortunately can’t. It is the latter group that, paradoxically, are often the hardest to treat; the group of patients who are at the end of their journey and for whom quality rather than quantity, in my opinion, is paramount. As I have progressed through my training, there have been wondrous new advances in cancer care that have become available to us in a relatively short space of time and this leaves us with a difficult conundrum. Should we strive to utilise everything in our arsenal right to the bitter end in the vain hope that we might meet with a little success? Do the side effects of our treatments justify this success? Or should we be taking a more pragmatic approach and take a step back sooner? Just because we can doesn’t necessarily mean we should.
So there it was. The end of a long lung cancer radiotherapy treatment clinic mostly full of exactly these patients – struggling to get through their treatment let alone everything else. In particular, the group that really struck me were my patients having whole brain radiotherapy for secondary cancers. Whole brain radiotherapy is tough. Lung cancer equally, once it has spread to the brain, is sadly not a good prognosis.
So why then are we putting our patients through this? Is it just to make ourselves feel better or will it actually work? Will it improve their quality of life? Crucially, will it benefit them in time? The danger, of course, is that the end will arrive sooner than the positive effects of treatment. The reality of this last sentence is not uncommon and the tragedy is that not offering treatment would, in fact, have been the better option. These were the questions that prompted our team to undertake this study; looking at whether palliative whole brain radiotherapy in lung cancer does indeed make a difference, or whether best supportive care really is best.
We found that quite a significant proportion of lung cancer patients with brain metastases at our centre did not survive to reap the benefits of their radiotherapy treatment. The main reason for this was that they were not fit enough for it in the first place. Indeed, just because we can doesn’t always mean we should.
Read the full article in the European Journal of Palliative Care
This post relates to a longer article, ‘Palliative whole-brain radiotherapy for cerebral metastases in advanced lung cancer: does it make a difference?’ by Hannah Buckley, Neel Bhuva, Alison Ranger, Niraj Goyal, Shiwen Koay, Julian Singer, Nishi Gupta and Girija Anand, published in the September/October 2015 issue of the European Journal of Palliative Care (vol. 22.5). If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.
Below are some links to US, German and UK information resources about the ‘Choosing Wisely ®’ campaign, a US initiative about avoiding wasteful or unnecessary medical tests, treatments and procedures.
- A Malhotra et al, Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine, BMJ 2015;350:h2308. (Open access).