When in Brooklyn I enjoy myself in a variety of uniquely urban ways. (I was back in the big city this week so that Debbie could meet with several book coaching clients.) I get my exercise by taking my three and five-year-old granddaughters to and from their respective preschools. This may not sound like much, but a one-way trip involves walking a total of 11 average city blocks, plus climbing and descending ten flights of stairs while carrying two lunch boxes and two sacks of indoor shoes to replace the snow boots once we arrive at the classrooms.
By the time I have taken off their winter garments, swapped out the shoes, and stuffed their cubbies, I am a ball of sweat.
Curiously, these distractible children, perpetually entertained by the mounds of dirty snow that line each sidewalk, do not share my sense of urgency about getting to school on time. Our “walk” involves a good deal of “encouragement.” How many times was I asked to comment on their footprints? How many times did we have to empty snow from their boots? “Your feet are going to be cold and wet all morning,” I say. “I don’t care,” is the response.
When not writing in the quietude of the Brooklyn Law School library, I have been enjoying lunches at ethnically diverse sandwich shops not available in mid-coast Maine (Cuban, Korean, Vietnamese), and dinners of fresh fish from my local fishmonger (trout, branzino, striped bass, also, unfortunately, not available in winter in coastal Maine).
[ Ed. note: the wine and cheese shop down the hill from us in Stonington sells a spectacular Vietnamese chicken banh mi sandwich.]
When not carrying lunch packs and dry shoes, I am making progress on my book
Having given my book proposal to my copyeditor, I am working on a potential op-ed (or NYTimes Opinionator) piece about the “Tyranny of Treatment,” a topic I address in my book. My thesis is that the default position of overtreatment in American medicine resonates with the unrealistic expectations of patients, especially elderly patients. Overtreatment leads to poor end-of-life decisions and ultimately the tyranny of “medicalized” deaths.
Slow progress on this writing project (I am working on my non-pedantic, compelling prose style) was brought up short by the President’s Oval Office signature of a memorandum creating the White House Cancer Moonshot Task Force.
How timely is this? How many sad ironies do the name and the date of this effort create?
The sad irony of the Cancer Moonshot Task Force
Thirty years, to the day, after the disaster of the space shuttle Challenger explosion, the headlines announce “Obama Takes First Step in a Cancer ‘Moonshot’” (NYT) and “Launching Cancer Moonshot, Biden Says Politics Impeding Cancer Cure” (WaPo). In the early paragraphs of the articles, the words “cure” and “optimism” abound.
Hoping to channel the successes of the space race to the moon, Biden characterizes the effort as a “moonshot to cure the disease.” Obama exhorts the readers with, “Let’s make America the country that cures cancer once and for all.”
Obama’s reality check for a 4th grader
Only late in the articles does a reality check take place, when the President is quoted speaking to a 4th grader, “It probably won’t be cured in my lifetime, but I think it will be cured in yours.” (Not, says the author of this blog.)
Later in the articles, Jose Baselga, M.D., president of the American Association for Cancer Research and Chief Medical Officer at Memorial Sloan Kettering Cancer Center is quoted, “A single approach to cancer…ain’t going to happen” and “Cancer, we’ve learned is far more complex than we’ve ever imagined. Every single tumor is different.”
Why didn’t either paper headline the comment of Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society, “Cancer will not be cured this year”?
A layman’s vs. doctor’s definition of cancer “cure”
Nowhere in the articles does the medical definition of cancer “cure” appear. To the reader a “cure” means long-term cancer-free existence. To a doctor, a patient is “cured” of cancer if they survive for five years after the diagnosis. It doesn’t matter how many treatments it takes, whether the cancer remains active at the five-year mark, or if the patient dies of the cancer at five years plus one day.
As a physician, I think that a five- year survival for most patients is achievable (at impractical expense) after several more decades of research but that long-term cancer-free existence for most patients is unrealistic. And, cancer-free existence for the elderly cannot be long term, by stipulation.
Yet, the impression that the politicians want to make is that finally the government (their administration) is taking charge and a “cure” is just around the corner. Unfortunately, the newspapers aid and abet this political PR message. Most people will read the first few paragraphs and assume that “victory” in the 50-year “War on Cancer” is at hand.
Two different interpretations of “moonshot”
I look at “moonshot” and I see two different interpretations. At worst, the most common use of “moonshot” means a ball lofted with a high trajectory, especially a court-length, last second, desperation basketball shot that is usually doomed to failure.
At best, the 1969 moon landing was an expensive, dangerous, difficult-to-reproduce success of dubious long-term value. This is not the “optic” the administration wants to project but it is ironically close to the truth.
Cancer treatments are already astronomically expensive and newer treatments will be exponentially expensive. With an aging population, elderly patients will make up an increasingly large majority of cancer patients and their “cures,” at great costs, will also be of increasingly dubious benefit. Complications – think the Challenger explosion – will be unpredictable and calamitous.
Of course, progress in cancer prevention, diagnosis, and treatment has been made and future progress must be undertaken and supported. Young people with a cancer diagnosis do gain valuable time with treatment and a significant percent are “medically cured.”
Overoptimism leads to futile overtreatment
But, presenting an overoptimistic outlook feeds into the unrealistic expectations of the American public and leads to increasingly futile overtreatment. Let me rant further: The New York Times and the Washington Post are being coopted by Obama’s political agenda (to “promise” a cure for cancer) when they publish misleading headlines about cancer.
Cynics will respond, “Caveat emptor,” to the subliminal message that “cure” is available. The elderly, in particular, will pay for false promises. They will pay with the discomfort and complications of near futile therapy and the loss of precious quality time.
It is not “news” to hear a politician announce the next attack in the 50-year “War On Cancer,” just as “Dog Bites Man” is not newsworthy in a national context.
Let’s have the President announce the creation of a task force that re-educates the American public and resets realistic expectations. The headline I want to see is: “We Are Not Going to Cure ‘Cancer’ in Your Lifetime.”
Oops, it is already time to collect a granddaughter and puzzle over her endless fascination with the mundane melting mounds of Brooklyn’s soot-tarnished snow. Luckily for her, there is no deadline getting home.
Sam. I read this piece with very personal interest. My mom died exactly two years ago today (talk about pertinent ironies), 5 months after having been diagnosed at age 89 with stage 4 pancreatic cancer. Typical of pancreatic cancers, hers was asymptomatic until the disease was well advanced. The first sign that something was amiss was a lack of appetite and noticeable weight loss about 4 months before her illness was finally identified. Up until this point, my mom was a model of good health–vibrant, active, walking several miles a day and involved in a plethora of activities with her (mostly younger) friends.
Once her diagnosis was confirmed, the medical industrial complex immediately seemed to shift into high gear. Her oncologist talking about scheduling her for chemotherapy treatments without asking whether treatment was, in fact, what she wanted. The doctor’s assumption seemed to be that since treatment was available (however dubious its benefits), it must be pursued. My mom interrupted her brisk monologue with a simple question: “How long will treatment extend my life?” The doctor paused uncomfortably. “About 3-6 months, in most cases” she answered. “And how long will I live if I do nothing?” “About 3-6 months.” “Then I won’t be having any treatment,” my mom said decisively.
She lived for five more months, dying two days before my brother’s and my birthday. (We aren’t twins but we share a birthday. I think she was trying to make it to that day, and she almost did.) She enjoyed visits with friends, took walks in the woods near her house, hosted her last Thanksgiving with her children and grandchildren, and savored one more blazing season of fall color on Connecticut’s back roads with one of us kids at the wheel. Her last month was pretty terrible–there’s no good way to die of cancer–but she lived her life as fully as she could for as long as she could, and died in her own bed in the house she loved. For that I will always be grateful.
This effort to lure elderly patients into expensive, painful, and fruitless treatment for cancer is as misguided as it is cruel. In promising an illusory ‘cure,’ patients will be robbed of the opportunity to die with the greatest measure of comfort and dignity. Let us resist these false promises and instead accept our own limitations with proper humility.
Thank you for so beautifully amplifying what Sam wrote.
Thank you for this. Your mother was one of the rare people whose feet were planted in reality and who did not suffer from the magical thinking that oncologists unconsciously prey upon.
When I first went into practice, common sense prevailed and people above a certain age and/or those with a diminished performance status were regularly counseled to decline chemotherapy. Before I left my practice, I was disheartened by a growing body of scientific studies that showed chemotherapy in the elderly “significantly” prolonged life expectancy. These studies usually resulted in a few months of added existence but finessed the “quality of life” experienced by the patient. Your mother’s oncologist clearly thought that she was on the cutting edge of medical care by offering a “statistically significant” number with 3 months of prolonged life. Lost on the oncologist is that “statistical significance” might not equal practical importance.
Forgotten in the exchange between doctor and patient is the fact that the pharmaceutical companies that benefit by manufacturing astronomically profitable chemotherapy agents are the organizations underwriting the “research.” There are many more layers to this but I have, already, gone on too long.
The goal of my book is to empower people to think like your mother and my father. Some people come to that way of thinking quite naturally, others need education and encouragement. Your thoughtful note has helped me crystalize some ideas.
My college classmates Yahoo group (class of 1963, so we are all in our 70’s) was discussing the “Moonshot” press release, so I sent along a link to your web page. I thought you might be interested in a posting on it from an MD in the class, Dr Jerry Crosby from South Carolina:
The article and the comments that followed are spot on. Not mentioned in the article is the frequent fact that it is not even the patient who is clutching at straws but the patient’s family. In talking with the family members I always asked them to stop and consider whether they were expressing the wishes of the patient or their own wishes. Whether the choices being made were for the the benefit of the patient or because of their own inability to accept the fact that their loved one was going to die and that somehow that could be prevented. The reeducation of our population to accept reality would be a great start. Again, the article is spot on.
One thing that keeps occurring to me is how society has “personalized” cancer. I’m sure you’ve see the advertisements from one hospital……”YOU tried to take my husband”…..”YOU tried to take me”…..and the references to the “battles”……”He put up a great fight”. I’m afraid your rational discussion of treatment vs quality of life” might carry the “he gave up” (i.e. he declined more treatment) stigma. One current cancer case, that of President Carter, might be a place to start your re-education of America towards realistic expectations, but as far as I know he is still into aggressive treatments.
Good luck with your book.
Don, thank you for these insights. There is a momentum to treatment, here in America, that is unsurpassed elsewhere. Jerry’s comment that treatment is frequently driven by family members and, your comment that there is a “stigma” attached to “giving up,” maintain that momentum. Both those factors could be mitigated if patients, before becoming too frail to self-advocate, discussed their end-of-life wishes and intentions with their families.
I agree that based on age alone President Carter’s treatments appear aggressive. His age-related performance status, however, is well above average and that probably justifies the chemo/radiation that he has undertaken. His challenge will be to tell his family at what level his future decline in performance merits refusal of further treatment.
Based on my remote perspective, it appears to me that President George H. W. Bush (whose performance status is comparatively reduced) has missed several “exit options” when he has submitted himself for prolonged hospitalizations for pneumonia. He now suffers Osler’s “‘cold degradations of decay’ so distressing to himself and his friends.”
Thanks again, Sam