Featured Article
Cancer Patients' Roles in Treatment Decisions: Do Characteristics of the Decision Influence Roles?
Article: "American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer"
Review: Dr. Daniel Epner's review of the article 
Jeffrey M. Peppercorn, Thomas J. Smith, Paul R. Helft, David J. DeBono,
Scott R. Berry, Dana S. Wollins, Daniel M. Hayes, Jamie H. Von Roenn,
and Lowell E. Schnipper
Journal of Clinical Oncology ASCO Special Article
Consider a 60-year-old woman in your clinic who underwent hemicolectomy and adjuvant chemotherapy 2 years ago for T3N1 colon cancer. Surveillance CT revealed multiple new hepatic metastases. You are about to leave the room after spending over 30 minutes getting consent for chemotherapy when she asks "Doc, how long do I have?" Consider the same patient two years later after her cancer has progressed despite extensive chemotherapy. Her performance status has fallen to ECOG 3, so she is no longer a candidate for additional anticancer therapy. These 2 scenarios and many others represent critical crossroads in the trajectory of cancer care. The types of conversations required during these crossroads present tremendous challenges and opportunities for us and our patients.
In this day and age, when we talk about "personalized cancer care", we usually refer to molecularly targeted, rationally designed treatments. However, the scenarios described above illustrate a broader definition of "personalized care", one that takes physical, psychological, social, and spiritual issues into consideration. Such an approach requires stepping back from the paradigm of applying one line of therapy after the other and moving toward one that is consistent with evidence-based options and the patient's informed preferences.
The current paper is an outstanding and important JCO position statement contributed by several leaders in the fields of healthcare communication, palliative care, and advanced care planning. In the introduction, the authors point out that transition to palliative care typically occurs far too late in the course of treatment or not at all. They state that we need to change the paradigm for advanced cancer care to include an earlier and more thorough assessment of patients' options, goals, and preferences, and to tailor the care we deliver to these individual needs throughout the continuum of care, not just at the end of life. The paper is divided into the following major sections: 1. goals for individualized care, 2. barriers that currently limit realization of this vision, and 3. strategies to overcome these barriers.
Goals of Individualized Care for Patients with Advanced Cancer
Goal 1: Determine whether we can treat the cancer. Despite many advances, chemotherapy controls advanced cancer for only months rather than years in the vast majority of cases. In addition, objective response does not always translate into improved quality of life or survival. Further, in many cases we simply have no options that are clearly beneficial, yet all interventions have some chance of toxicity. Given these limitations of current therapy, the authors point out that treating the cancer should be viewed as an option for discussion rather than a default.
Goal 2: Maximize quality-of-life. When patients have no reasonable therapeutic options remaining, they should be encouraged to transition to palliative care.
Goal 3: Maximize enrollment in clinical trials.
Barriers to Achieving Individualized Care for Patients with Advanced Cancer
Barrier 1: Candid conversations can make us feel like we are giving up or admitting failure.
Barrier 2: Most of us have little or no training in how to engage in these candid conversations. These conversations are particularly difficult, because we so often reserve them for late in the course of a patient's illness, rather than developing an open dialogue early in the course of routine care. Not surprisingly, such conversations currently occur with only about 40% of patients with advanced cancer.
Barrier 3: These conversations are typically very time-consuming, difficult to accomplish in a typical follow-up visit, and not paid for.
Keys to Successfully Providing Personalized Cancer Care
Key 1: Emphasize Individualized Care in Education, Training, and Quality Improvement Programs
- Teach oncologists how to engage in candid conversations around personalized cancer care during oncology training, certification, and continuing medical education.
- Incorporate palliative care into American Board of Internal Medicine training
Key 2: Support Individualized Care. Reimburse oncologists for discussing a patient's goals and preferences and providing individualized care.
Bottom Line: This paper is a must read for anybody who cares for cancer patients.
Daniel Epner, M.D.
Associate Professor, Department of General Oncology
Dr. Epner received his medical degree from Baylor College of Medicine and completed his clinical and research fellowship in medical oncology at Johns Hopkins School of Medicine. Dr. Epner's primary clinical focus is on the international oncology patients seen in the International Cancer Assessment Center (ICAC). Dr. Epner has published several articles in peer-reviewed journals and is developing research and educational programs to improve communication between cancer patients and their providers and to study the role culture plays in oncology practice.
