To Treat Or Not To Treat

I wrote about the sad demise of my cousin in my last post. The trauma faced by his family during the brief period between diagnosis and his death was painful indeed.  The diagnosis was metastasized renal cell carcinoma.

He contracted cancer for the first time five years ago. It was a growth in one of his kidneys. The kidney was removed and all neighboring lymph nodes cleaned by the surgeon. He recovered and started leading a normal life. Periodical followups were satisfactory and went on for three years. He was declared cancer free. Normal life, with his normal ailments of diabetes, hypertension and enlarged prostate, continued for one more year. In the fifth year he developed another problem. He started having bouts of dizziness and losing balance while walking. This was initially thought to be vertigo. He was also diagnosed with CLL (Chronic Lymphocytic Leukemia.)  However the haemo-oncologist reassured us that it had nothing to do with his renal cancer.

Unfortunately, what was thought to be vertigo was later found to be a cancerous growth in the brain. Further investigations showed a growth in one of the lungs too.  Biopsy results showed that it was renal cell carcinoma that had metastasized to other organs.

My niece is a doctor and member of a WhatsApp group of doctors with varying specializations.  She consulted the oncologists in the group and they were almost unanimous that it will be best to stop looking for a cure and go for palliative care instead.  They estimated the remaining life span at 3 to 6 months. They also described the likely and frightening after effects of radiation and cancer medication. In their opinion the treatment, even if it succeeded in prolonging life, will also aggravate the misery. The alternative of palliative care was likely to ensure a relatively better quality of life for the patient for whatever span was left to him.  Needless to say that this group had no commercial interest in the matter.

My niece also spoke with some of the families that had lost an aged member to cancer.  All of them regretted having gone for the treatment and were of the opinion that the patient would have been better off without it even if it had meant a shorter residual life.  Much later, after we were in the middle of treatment, I learnt of the sad death of a friend; again due to cancer.  His wife sorely regretted having gone for aggressive treatment thereby prolonging and intensifying his misery.  She strongly advised us to ignore oncologists and go for palliative care only.

It was too stark an advice to be fully shared with the patient and those closest to him.  Carefully worded soft disclosures and hints at the alternative course led to a state of indecision.   The local medical oncologist insisted that the patient be put through entire regimen of treatment which could extend his life by an year or more. He ordered umpteen tests too.  Finally he prescribed radiation therapy for the brain.  The radiologist decided in favor of whole brain radiation instead of one focused on the tumor only.  As the family could not decide on the option of palliative care, my cousin, the patient, underwent 10 radiation sessions. He was also put on a heavy dose of steroids for the duration of radiotherapy.

The steroids did wonders to improve the patient's sense of wellbeing and he sailed through radiotherapy without much visible adverse effects.  Though, hair loss did start by the end of the therapy.  We thought that those advising against radiation were a bit of alarmists.  Thereafter steroid was gradually withdrawn leading to progressive worsening of condition.  Next the cancer drug Votrient was started.  Oncologists in my niece's group again advised against it.

The attending oncologist had prescribed the maximum dose of 800 mg.  However in view of the concerns expressed in online consultations, it was decided to reduce the dose to 400 mg.

From here it was downhill all the way.  Many of the after-effects of radiation started showing.  Votrient seemed to do little to slow down the growth of the cancer while it aggravated the downfall.  The patient suffered from hypersomnia (sleeping most of the time,) severe weakness in limbs and loss of control over bladder and bowel movements.  Other complications like urinary tract infection (UTI) and thrombosis developed and required hospitalization for treatment.

No improvement was noticed even after a month of taking Votrient and other treatments for infection and thrombosis.  The doctor finally decided to stop Votrient for a few days and we prevailed upon him for discharging the patient.  We made arrangements at home for administering intravenous drugs, started using adult diapers and finally arranged an oxygen kit too.  In the last two-three days the patient stopped interacting with people altogether, ate very little, was extremely restless and his limbs were trembling all the time.  He died in the wee hours on 18th April, nearly three months after the metastasized cancer was detected for the first time.

All of us are convinced that it would have been far better to go for palliative care.  We were told that such care could be given by a normal MD to relieve symptoms and pain and steriods could be given to impart a sense of wellbeing.  In this scenario there was little sense in considering the long term adverse effects of steroids.

My niece's husband, a doctor himself, summarized the whole thing quite succinctly.  He said that the family could not bring itself to accepting the sane advice of putting the patient on palliative care; and that any other family that was unfortunate enough to consult us in this matter, would surely ignore our own advice based on our harsh experience.  In the choice between quality of life and painful longevity, howsoever little, the latter, unfortunately, always seems to prevail.  And thus the practice of oncology goes on.

I have a feeling that all practicing oncologists treating a patient advanced in age and suffering from metastasis, should be mandated to compulsorily offer the second option of palliative care only.  Few do so currently.