Oncologists are experts in evaluating the nature of cancer, how it’s treated, and the side effects of the treatments used. As cancer treatments continue to improve, oncologists constantly assess their patients’ best options but do patients always listen?
Certain types of cancer have genetic markers that can make them more responsive to targeted therapies. For example, testing people with non-small cell lung cancer (NSCLC) for epidermal growth factor receptor (EGFR) and ALK mutations, which are gene changes, can help doctors decide whether to recommend specific targeted therapy drugs.
Doctors usually recommend biomarker testing for your cancer as it could impact a patient’s treatment plan.
What other health factors do oncologists consider when making treatment recommendations?
Certain medical conditions, like heart disease or diabetes, should be considered when planning cancer treatment and recovery. Because of this, your oncologist will review your complete medical history before making any treatment recommendations. Learn what to know when cancer is not your only health concern.
An oncologist will also consider a person’s age when recommending a treatment plan. Oncologists treating people over age 65 increasingly use geriatric assessments to decide which treatment options are best for their patients. Geriatric assessments identify problems that might not be captured during a traditional physical exam and are more common in this age range. It’s important to note that a patient’s age should be just one of many factors considered in making treatment recommendations.
When considering specific treatments, short-term and long-term side effects are also top of mind for oncologists. This includes talking with the patient about their goals for care, the physical, emotional, and social effects of cancer, and the financial impacts of treatment. Quality of life is an important consideration when making treatment recommendations. The healthcare team will pay close attention to how treatments may impact someone’s overall comfort, well-being, and ability to partake in their usual tasks and the things they enjoy.
But will patients listen and make the right choice?
Although refusal is a fundamental human right, as is asking for treatment the physician may consider futile, physicians can resolve the problem a significant percentage of the time, said Eduardo Bruera, MD, Chair and Professor in MD Anderson’s Department of Palliative Care and Rehabilitation Medicine. “Patients have to make decisions under challenging circumstances, particularly when they are getting to the level of having very advanced cancer. The emotional component drives a lot of the decision-making. Cognitive aspects—where my cancer is and my odds—are only part of patients’ decision-making, so we need to understand their emotions.”
Current evidence suggests that healthcare professionals often feel uncomfortable, troubled, and even distressed when dealing with patients who decide against medical advice. In such situations, communication between patients and the healthcare team can become strained, impacting future contact and the quality of therapeutic interaction.
We tend to think that refusing therapy leads to a poorer quality of life as the disease progresses without treatment. Interestingly, that might not be the case.
A study that evaluated the quality of life of 140 cancer patients who had refused, discontinued, or completed chemotherapy revealed that the quality of life of patients who refused or discontinued chemotherapy was no different than that of patients who completed treatment.
When cancer patients share their rationale for refusing conventional treatment, they mention multiple reasons, such as fear of adverse side effects of cancer treatment (particularly chemotherapy), uncertainty about treatment effectiveness, hopelessness, helplessness, loss of control, denial (about their illness), psychiatric disorders, dysfunction in the health care system, and, above all, issues surrounding communication and the patient-physician relationship.
The unique patients who refuse conventional treatment are, at times, self-directed, confident, and active. They have thought deeply about the meaning of life, cancer, and cancer treatment options.
Why More People Are Refusing Chemotherapy
Chemotherapy encompasses a range of medications explicitly used to eradicate cancer cells within your body. Most commonly, it’s referred to as chemo for short. Chemo drugs target and destroy cells in your body that rapidly divide—or mutate—in the case of cancer cells. The side effects can be numerous because many cells rapidly divide in your body, including those of the gastrointestinal tract, hair, skin, and nails. The drugs meant to kill the cancerous cells also destroy these healthy cells, resulting in chemotherapy’s most common side effects.
Condemning personal experience stories are plastered over web pages and personal blogs, most of which exploit the fatigue, hair loss, and more distressing side effects experienced while taking chemotherapy. Notice we said it could be experienced—not everyone suffers the extreme side effects commonly associated with chemo.
Sometimes treatments work, and sometimes they don’t, but not many people refuse traditional treatments. According to a study cited by Dr. Moshe Frenkel in The Oncologist, less than 1% of patients refused all conventional treatment, while 3% to 19% refused chemo partially or completely.
Complementary and alternative medicine (CAM) has become increasingly popular in the U.S. and among cancer patients over the past few decades. People with cancer might use complementary therapies alongside standard medical care—or, in the case of alternative medicine, instead of it. Little evidence exists to support the efficacy of complementary or alternative medicine to treat cancer (and replacing standard care with alternative treatments can be life-threatening.)
One study published in JAMA Oncology in 2019, using data from 2012, suggests that about 33% of cancer patients in the U.S. use CAM. The actual number is likely much higher—probably around 80%, says Dr. Steve Vasilev, medical director of integrative gynecologic oncology at Providence Saint John’s Health Center and professor at Saint John’s Cancer Institute in California.
There is hope, however. There are currently more than 700 oncology drugs in late stages of development. This number represents a 60% increase from a decade ago, as cancer drugs continue to represent a more significant part of the overall drug pipeline.
The Estimated number of new cancer cases and deaths in 2022 (In 2022, an estimated 1.9 million new cancer cases will be diagnosed and 609,360 cancer deaths in the United States.)
Substantial progress has been made against cancer in recent decades. The best measure of this progress is cancer death rates (also called mortality rates) because they are less affected by changes in detection practices than incidence (new diagnoses) and survival rates. The overall age-adjusted cancer death rate rose during most of the 20th century, peaking in 1991 at 215 cancer deaths per 100,000 people, mainly because of the smoking epidemic. As of 2019, the rate had dropped to 146 per 100,000 – a decline of 32% – primarily because of reductions in smoking and advances in early detection and treatment for some cancers. The decrease in the death rate translates into nearly 3.5 million fewer cancer deaths from 1991 to 2019, primarily driven by progress against the four most common cancer types – lung, colorectal, breast, and prostate.
To understand how cancer patients make treatment decisions, Oncologists must be more than just physicians; they must be able to put themselves in the patient’s place and understand their motivations. I lost a friend due to lung cancer when he refused surgery that would have, in all likelihood, removed his cancer and allowed him to live 20-30 years. When I asked Dan why he refused surgery, he thought a cancer diagnosis was “the end.” Sadly, some patients get tired of fighting the disease and want to end their lives with dignity and pain-free.