The goal of advanced cancer treatment is not “cure” but “control”.
Due to the incurability of most advanced cancers, it is especially important to weigh the pros and cons when treating them, and the general principle is “to ensure the interests of patients, so that they can live long and well”.
Spiritual factors have a great influence on the occurrence and development of cancer, and the commonality of “miracles” is a good state of mind
According to media reports, Chen Zuobing, a medical doctor and emergency specialist at Zhejiang Medical College, learned that his 78-year-old father had an advanced malignant tumor that had metastasized throughout his body and was inoperable, informed his father of his condition and respected his father’s wishes by sending him back home to Zhuji from Hangzhou to live out his final life without radiation or chemotherapy. Chen Zuobing’s approach has won the approval of many ordinary readers, and even some family members of cancer patients said they also wanted to do that, but they just couldn’t accept it emotionally.
Usually, when cancer reaches an advanced stage, there is not much hope for a cure. At such time, patients always face the confusion: should they treat, or give up? If they spend a lot of money on treatment and end up with “no money at all”, is it not worth the loss? Others feel that it is better not to treat the patient and let him/her spend the last days in peace than to let him/her go through all kinds of pain in the treatment. What do the specialists think about these views? On the occasion of “World Cancer Day”, the reporter interviewed oncologists to listen to their thoughts.
About the purpose.
The purpose of treatment is to “live long and well”.
Reporter: When cancer reaches advanced stage, there is little hope for cure, and many people think there is no meaning of treatment. As a specialist doctor, what do you think?
You Changxuan: Advanced cancer usually refers to local spread or distant metastasis due to tumor infiltration, which is usually referred to as spread and metastasis. Advanced cancer is indeed a disease that is difficult to be cured, but there are still some advanced cancers that may be cured through standard treatment, such as choriocarcinoma, testicular germ cell tumor, malignant lymphoma, etc. Most of the advanced cancers are not curable, but they are not. Most of the advanced cancers cannot be cured, but through effective treatment, the survival of patients can be significantly extended and their quality of life improved, for example, for advanced lung cancer with EGFR gene mutation, the median survival can be increased to more than 30 months after treatment; for advanced bowel cancer, the median survival can be increased to more than 24 months; for advanced breast cancer, the median survival can also be increased to more than 35 months, and some patients with advanced cancer Some advanced cancer patients can even survive with tumor for a long time. For these advanced cancers, the goal of treatment is not to “cure” but to “control” them, to achieve survival with tumor and coexist with human tumor.
This control mainly includes two aspects, one is to prolong the survival time of patients, and the other is to improve the quality of life of patients, which is commonly known as “to live long and well”. For common malignant tumors such as lung cancer, breast cancer, intestinal cancer, etc., the existing means can basically meet the treatment needs of patients, so it is wrong to give up negatively.
Regarding the choice of.
”To treat or not to treat” should be analyzed individually
Reporter: Many advanced cancer patients are torn between the fear of losing their chance without treatment and the fear of wasting their time.
You Changxuan: Clinically, besides considering medical evidence and doctors’ experience, another very important factor in choosing treatment is patients’ interests. How to ensure the interests of the patient is the clinician’s full consideration, and often the primary condition for deciding whether to treat or not. This requires effective communication between doctors and patients, so that patients and their families can clearly know what medical treatment can and cannot do, how much benefit it can bring to patients, and how much cost patients need to pay, including the possible adverse effects and the economic pressure they need to bear. After fully understanding the pros and cons of treatment, it should not be difficult to make a decision on “to treat or not to treat advanced tumors”.
The decision of “to treat or not to treat advanced tumors” should not be difficult to make after fully understanding the pros and cons of treatment. For example, for a patient with stage IV lung cancer and bone metastasis, the patient’s age, physical status, molecular markers, clinical symptoms and other factors should be fully considered when deciding on treatment. The cost of chemotherapy and radiotherapy can be reimbursed by medical insurance, and the financial burden of patients is not great. Even with molecular targeted drugs, if there is EGFR gene sensitive mutation, Guangzhou medical insurance patients can apply for specific outpatient programs, and foreign medical insurance patients can also apply for charitable gifts from China Charity Federation, so for such patients, they should be given active treatment.
For patients with the same stage, even if they insist on active treatment, they should be persuaded to give up the treatment plan with more side effects and choose targeted drugs with less side effects or immunotherapy, Chinese herbal medicine, or even purely psychological treatment through molecular target testing, if they are of advanced age, poor physical condition, or have serious comorbidities such as diabetes or cardiopulmonary insufficiency. In conclusion, due to the incurable nature of most advanced cancers, it is especially important to weigh the pros and cons when deciding on treatment, with the general principle – to fully ensure the patient’s interests and try not to increase the risk or shorten the survival period.
Regarding treatment.
It’s about looking at the “patient” and treating him or her
Not “disease” treatment
Reporter: Most cancer patients will choose treatment, and their families hope that the money spent will have an effect.
You Changxuan: Generally speaking, in the early or middle stage of cancer, the tumor does not have distant metastasis, and if the diagnosis is clear, the patient will receive surgery, and after surgery, according to the pathological type and stage, the patient will decide whether to receive adjuvant chemotherapy or radiotherapy, and the treatment plan is not complicated. In advanced stage of cancer, the disease is often more complicated, and individualized treatment is emphasized at this time. The general principle is to look at the “patient” to treat the disease rather than the “disease” to treat the disease.
For example, the same advanced lung cancer has different pathological types, from adenocarcinoma to squamous cancer; different driver genes, from EGFR gene mutation to EML4-ALK gene fusion; different metastatic sites, from brain metastasis to bone metastasis; different physical status, from good physical status to bad physical status… …need to develop a treatment plan based on individual circumstances.
Currently, the most individualized treatment is molecular targeted therapy. For example, about 25% of patients with refractory breast cancer are saved and their lives are prolonged due to the in-depth understanding of HER-2 expression and the use of the corresponding drug Herceptin, and the expression of HER-2 gene in breast cancer patients determines the efficacy of Herceptin; whether or not EGFR is mutated in lung cancer patients is closely related to the efficacy of EGFR-TKI drugs, and it is Gefitinib (ERSA), Erlotinib (Tro Kay), and erlotinib (Kemena), as well as a prognostic predictor for lung cancer patients. Patients with EGFR-sensitive mutations treated with EGFR-TKI have an objective remission rate of up to 70% or more and a disease control rate of up to 90%. Of course, not all tumor patients can benefit from molecular targeted therapy, and the high cost of drugs also dictates that we cannot try drugs without certainty, so we need to test patients’ relevant drug targets and select appropriate drugs before using them to truly “target” them.
For those patients who are not suitable for molecular targeted therapy, they still need to rely on chemotherapy and radiotherapy to control their disease. The treatment plan for these patients can also be personalized. When formulating the plan, it is necessary not only to know the height, weight, body surface area, pathological type, stage, and physical status of the patient, but also to test the drug-related gene expression, so as to assess the sensitivity and possible toxicity of the individual to the drug. This information is combined to develop a treatment plan that maximizes efficacy and minimizes toxicity.
Finally, the development of a treatment plan also requires consideration of the patient’s affordability. For example, some patients are financially well off and do not consider issues such as health insurance reimbursement, so there is more room for choice; some patients are more economically challenged, so we will choose drugs that are reimbursed by health insurance as much as possible while ensuring efficacy. Of course, we will also advise patients to actively participate in various clinical studies so that patients can not only receive the latest drug treatment, but also completely free of charge.
”The key is that there must be full communication between the patient and the doctor, with the doctor understanding the patient’s expectations and ideas and the patient being clear about the role and limitations of medicine, weighing the pros and cons before deciding on a treatment plan.”
On value.
Some technologies can already assess the degree of benefit
Reporter: Some people say that it is very worthless to treat advanced cancer and spend a lot of money to prolong life for a few months, what do you think?
You Changxuan: Clinically, patients often ask me, “How long can I live if I am willing to spend $1 million on treatment?” I can only say that treatment is better than no treatment, but the degree of benefit is different for each person. Some people may spend $1 million to extend their life by only 2 months, but others may spend $50,000 or even no money (such as participating in clinical research) to extend their life by several years, but with the advancement of medical treatment, there are now many ways to assess the degree of benefit in advance, so that patients do not spend money in vain, which is reflected in the treatment of moderate and precise treatment rather than excessive blind treatment.
At present, for chemotherapy, the clinical selection of drugs is mainly based on evidence-based medicine, and the detection of biomarkers such as ERCC1, RRM1, BRCA1, and TS enzyme expression levels can predict to some extent the efficacy on common chemotherapy drugs such as platinum, gemcitabine, paclitaxel, and pemetrexed.
In addition, for targeted therapies, we already have more reliable biomarkers and sensitive assays that can predict efficacy and assess prognosis, telling patients more precisely, “how much I will benefit from what I spend, and even approximately how long I will live. Current molecularly targeted drugs for lung cancer, breast cancer, malignant melanoma, and non-Hodgkin’s lymphoma all have relatively clear biomarkers that can guide treatment.
Of course, patients, doctors and relatives alike should not focus only on financial figures, because life is priceless and “living is the hard way”. We should give patients the opportunity to live as long as their financial capacity allows, “the patient’s own wishes should be fully respected, and we should try to let patients live with dignity and quality, so that patients, relatives and friends as well as doctors have less regrets.”
On miracles.
A good attitude is the commonality of miracles
Reporter: In the cancer world, there are often some miracles circulating, such as so-and-so was sentenced to death, but he is still alive and well after several years.
You Changxuan: The situation you mentioned does exist in clinical practice, and I have encountered several of them myself. I was impressed by an old farmer from Huadu who was diagnosed with advanced malignant lymphoma. When he was admitted to the hospital, his condition was very serious and his body was very exhausted. I didn’t expect that three years later, this old farmer came back to me with his health basically restored, and he was as good as before.
Later, we did some analysis and found that these “miracles” have commonalities: First, although the tumor is malignant, it is an “inert tumor” and does not progress fast. The second is that the patient has a good state of mind, like this old farmer, who is very cheerful and open-minded and has no psychological burden, which is very important. Science has proved that mental factors have a great influence on the occurrence and development of cancer. A good state of mind can enhance the immunity of the body and thus improve the efficacy of treatment. Therefore, I suggest that tumor patients should not always look at themselves as patients, and maintain a normal life as much as possible, even continue their original work, participate in more recreational activities, and keep a healthy mind as long as their physical condition allows. If patients do have greater psychological pressure, appropriate medical intervention is also necessary.
In clinical practice, we also attach great importance to adjusting the patient’s psychological state, as the saying goes: “Adjusting the disease first adjusts the mind”, “No mind disease is no body disease”, a good mind will often achieve good results.