When Celebrities Vow to Beat Their Cancer

I can admire celebrities who are willing to be open about their illnesses because it brings important discussions to the fore and offers multiple teaching opportunities. But we need to change the discussion involving advanced cancer from the usual plan to beat the illness to something more nuanced.

The most recent example of this is Alex Trebek, the emcee of the wildly popular and long-running game show, Jeopardy! Although I was saddened to hear that he was diagnosed with stage IV pancreatic cancer, I was pleased to hear of his upbeat approach and to view his general good physical appearance. I interpret this to mean that he can find some good quality time if he does not waste it in hospitals and clinics seeking an unlikely cure. But I fear most other observers won’t share my view.

The media feeds a go-for-broke attitude

Most others will applaud his go-for-broke attitude. But this is where a celebrity’s bully pulpit gets misused. Because his personal goal is to “beat the low survival rate statistics for this disease,” and, by assuring the audience that with their help he will “win,” the media’s repetition of his aspirations without modification makes his success appear inevitable.

Now there is evidence that optimists tolerate toxic treatments better than pessimists, but there is no evidence that they live longer. So the likelihood is that he will suffer treatments without practical benefit.

An opportunity for a teaching moment

By going public with his troubles he has an opportunity to offer a teaching moment. If he dies from the disease he will be hailed for his bravery and his public’s eyes will be collectively opened. But if he survives as he predicts, without describing the trials and challenges of his treatments, he will only serve to mislead observers.
Worse yet, if he is “cured” against all odds, without sharing his ordeal, he will inspire thousands to follow in his footsteps when they would be better served by palliative care.

The MD Anderson nomogram for stage III pancreatic cancer (indeed, they don’t include a prediction for stage IV illness) predicts a 1-2 percent survival at 36 months for a 78 year-old male. So, although he has vowed to “beat” his illness (a cancer cure is defined as living five more years), the likelihood of such success is exceedingly slim. Although I wish him well, I am distressed that news reports did not emphasize the reality of his situation.

Magical thinking is misleading

No one can will oneself a cure, although it is an enduring example of magical thinking our culture has come to embrace. This is best exemplified by Stephen Jay Gould’s widely praised but largely misleading 1985 essay, The Median Isn’t The Message.
We can will ourselves to get out of bed; we can will ourselves to undergo surgery; we can will ourselves to tolerate another course of toxic chemotherapy or another round of debilitating radiation. But we cannot will ourselves to land at a particular spot on the survival curve of our illness.

For 78-year-old patients, the median is, in fact, the message. That’s because the longest living survivors will always be those who start with the advantage of youth and a robust physiognomy.

And don’t let posturing politicians, misleading advertisements, and hyperbolic health care hacks fool you into undergoing painful treatments because of the promise of improving results. Between 2002 and 2014, the FDA approved 72 new medications for the treatment of various cancers. Each one claimed to be part of breakthrough technologies and each one is associated with extraordinary cost. But if we compare the average gains for progression free survival and overall survival of these new treatments with the standard results, the miraculous benefits prove to be an increase of only 2.5 and 2.1 months respectively. This hardly represents curative treatments.

Good days wasted vs. bad days gained

We must balance our optimism with reality. We must not allow aspirations to become assumptions. We must emphasize that for every one or two patients who undergoes aggressive chemotherapy and lives 36 months with stage IV pancreatic cancer, there are 98 or 99 who did not. And of those, some died prematurely because of treatment complications, many suffered debilitating side effects, and all spent time in treatment centers that might more happily have been spent elsewhere with friends and family.

Were these good days wasted or bad days gained? Well, that is the proverbial conundrum of our perspective on what a half a glass of anything represents.

Have a backup plan for palliative care

If I were 78 years old and diagnosed with an advanced cancer I would assess my overall health, including the presence of other illness and my ability to care for myself. If I suffered from another non-cancerous chronic illness and if I were frail, I would strongly consider seeking a palliative care consultation and foregoing aggressive treatments. Because I know that whatever number of “good days” were allotted to me, by undergoing aggressive treatments, I would immediately start wasting them in hospitals and clinics or at home with side effects. And, I would be guaranteed to suffer without a significant likelihood of practical, measurable benefit.

If I were as robust and independent as Alex Trebek appears to be, I would proceed with treatments cautiously. With my physician, I would study my disease trajectory, monitor my progress, review my advance directives with my family and friends, and I would establish a back-up plan for palliative care followed by hospice care if I became debilitated by side effects or complications.

Projecting blind optimism isn’t enough

When we go public with our medical trials, we have a responsibility to project more than blind optimism. We have a responsibility to amplify the facts, distinguish hope from consequence, differentiate aspiration from axiom, and broaden our definition of beating advanced cancer to include managing an impossible situation well.

Finally, we must urge the media to reinforce the reality of current treatments and to ignore overly optimistic information designed to be confused with fact, leading to over-expectation on the part of patients and over treatment, indeed futile treatment, by physicians.

Useful Reading

A recent study:

Unintended Consequences of Expensive Cancer Therapeutics: The Pursuit of Marginal Indications and a Me·Too Mentality That Stifles Innovation and Creativity

4 Responses to When Celebrities Vow to Beat Their Cancer

  1. Jonathan March 22, 2019 at 2:42 pm #

    Thanks for this. The Merck Manual section on pancreatic cancer is very frank: “Ultimately, most patients experience pain and die.”

    I hope Mr Trebek manages to find a way to be comfortable and to make the most of his remaining time… and I hope his physicians can help him control his pain, with opioids if appropriate, in spite of political attempts to restrict access to these drugs.

    • Sam March 26, 2019 at 2:02 pm #

      Jonathan, thank you. I am hoping that cancer pain is one of the areas where politicians will not restrict access to narcotics.

  2. Tara Rolstad March 24, 2019 at 1:57 am #

    I love Alex Trebek as much as the next guy (though not as much as my mom or mother-in-law), but Sam has some important thoughts here about the messages celebrities send when sharing their medical journeys. Sam doesn’t come out and say it, but I will. Alex may well experience better than average outcomes because of his access to wealth and good medical care, but if neither he or the media acknowledge that factor of his situation, others who don’t may feel like they failed, or didn’t try hard enough. Of course, it’s possible that even Alex Trebek may express overly optimistic views as a way to bolster his own courage in the face of a difficult situation, which would be completely understandable.

    • Sam March 26, 2019 at 2:01 pm #

      Thank you, Tara. Mr. Trebek might well be bolstering his courage and if he is doing so because he is well informed, I support that wholeheartedly. And your point about the well to do having access to better medical care is, unfortunately, completely accurate. There is a risk, however, that celebrities don’t always understand. Doctors who practice in the reflected glory of their celebrity patients are willing to break the rules for them and in doing so place them at increased risk. Joan Rivers died because she underwent two (probably unnecessary) endoscopies at one sitting without the proper preparation for the potential of one complicating the other. Why? Her convenience, most likely. And Steve Jobs died from delaying standard treatment for his uncommon, but eminently treatable, neuroendocrine cancer of the pancreas. When it was first discovered, surgery offered a 95% chance of cure. Deferring to his celebrity eminence, his providers enabled his therapeutic misadventure until his treatable cancer had grown into an incurable stage.Treatments should be evidence based, not eminence based and celebrities would do well not to ask for special treatment.

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