Use of Chemotherapy in Treating Cancer
In his response (Letters, Jan. 22) to my article (Editorial Pages, Jan. 9), “Chemotherapy: Snake-Oil Remedy?,” Dr. Gregory Sarna referred to two randomized controlled studies, which he indicated have shown “survival benefits with chemotherapy plus radiation for limited pancreatic carcinoma.” Both were led by Dr. Charles Moertel of the Mayo Clinic.
In the more recent paper, the authors concluded, “although this study does provide some evidence of a therapeutic gain in pancreatic carcinoma, the gain can hardly be considered substantive. Median survival was increased by only a very few weeks, many of which were spent undergoing a treatment procedure.” They asserted that there is “no justification” for adopting the treatment they employed “as standard therapy for this disease,” but hoped that their study would “serve as an impetus for further research directed to improving results for locally unresectable pancreatic carcinoma.”
Dr. Sarna also referred to a Canadian study, which he believes “supports improved survival” in lung cancer. This study has not yet been published in a scientific journal, where it can be scrutinized and where a scholarly audience can judge the validity, the generalizability and the importance of the findings in relation to any adverse effects of treatment. Hopefully, this or another study will in the future provide unequivocal evidence of benefit of treatment in this disease.
Dr. Charles Haskell (Letters, Jan. 22) acknowledges the “technical” truth of my arguments about cancers that respond poorly to chemotherapy, but suggests that they “would have been better left unsaid,” because they would deny hope to patients. There always is hope, in the form of experimental treatment, which can be acknowledged as such. That should not be confused with false optimism.
As a general internist, I believe that physicians should be strong advocates of treatments for which there is convincing evidence that they relieve symptoms or prolong life; this is the case for chemotherapy in many, but not all cancers. At the same time, physicians should not be evangelists for any particular therapy, when more than one option is reasonable, and should not be bound to one style of relating to patients: we should respond to the patient’s own needs and goals.
Some patients do not want to discuss their prognosis; others do. Some want to try anything that might have a chance of helping; others are more skeptical and are interested in precise data on the value of treatment. Information that treatments for some diseases may not be effective should not be a professional secret.
If the public discussion of this matter encourages more patients to engage in a dialogue with physicians about proposed treatments, I believe that the public good will have been served and that doctor-patient relationships may actually improve.
MARTIN F. SHAPIRO MD
Los Angeles
