Prof. Nathan I. Cherny, MD: The Evolving Role of Palliative Care in Cancer
Prof. Nathan I. Cherny sits down with The Group Room at EMCC 2011. Dr. Cherny discusses the role of palliative care in cancer treatment. He also talks about how he got into palliative care and surviving testicular cancer as a first year medical student.
The Group Room at the 2011 European Multidisciplinary Cancer Conference was made possible, in part, by:
VIDEO TRANSCRIPT
Selma Schimmel, Founder & CEO, Vital Options International:
This is Selma Schimmel at the Multidisciplinary Cancer Congress 2011 in Stockholm. Today we’re joined by Professor Doctor Nathan Cherny. Professor Cherny is the Norman Levin Chair of Humanistic Medicine at Shaare Zedek Medical Center in Jerusalem. Professor Cherny when is enough, enough when it comes to treatment?
Prof. Nathan I. Cherny, MBBS, FRACP, FRCP, Dir., Cancer Pain & Palliative Medicine Service, Shaare Zedek Medical Center, Jerusalem:
Unfortunately for patients whose illnesses are not going to be curable there comes a point where the diseases are essentially resistant to further treatment options, and administration of further treatment is likely to harm than to help. And one of the messages I always give to patients is that chemotherapy or biological treatment radiotherapy this is not the treatment. This is one tool part of a whole person care package, and if at any point it’s doing more harm than good it shouldn’t be there, and we need to be focusing somewhere else.
We talk to people about courage. Often the portrayal of the courageous cancer patient is the person who says ‘I’m going to take another treatment no matter how difficult and how challenging it is’. But there’s a different sort of courage as well, and that’s the courage to say look, to be able to deal with the changed reality to say that ‘this isn’t good for me’ and to say that ‘right now I’m going to take the courageous step of refocusing my priorities on my family and on my loved ones, and feeling as comfortable as I can, on issues of legacy’. One of the important things that I want to be leaving behind for my family. These aren’t easy and by being able to talk about things like courage, love, as part of the oncological dialogue this is really part of the skillset required to help move people down this path.
Selma Schimmel:
But it seems to me that there’s yet another dialogue that has to happen which is that the dialogue about this very natural component about living and life, which is also about dying. And our culture doesn’t seem to foster and encourage those discussions.
Prof. Nathan I. Cherny:
I think that that’s very true, I think in the different worlds that I’ve worked in – United States, Australia, Israel, and Europe – I think there are multiple different ways in which people deal with it. The media in a sense are fostered death denying culture which often makes our work much more difficult. But the truth of the matter is we say this – the book says all our lives come to an end. And that no one wants to actually confront this, from any patient this is going to part of the evolution of the disease and unless… you could either confront this and deal with this in a constructive way or it can it can become a major ordeal with the expenditure of enormous amounts of time and energies pursuing futile things that not only may not help but they may actually harm and undermine the time that’s left.
Selma Schimmel:
What is a quality death?
Prof. Nathan I. Cherny:
Death is not a sudden event – death is a process leading to the end of life. And the things I try to emphasize with my patients relate to relationships and to love, to issues of legacy of the paths of you that you would leave behind to people that are going to continue on afterwards, and comfort. Maybe in time should find comfort and function because even with people whose health is deteriorating we strive to try to keep them as functional as possible as long as possible. And when we say that people have got strong bonds and relationships or are fostering and using this time with their important relationships when we can say that they’ve had the opportunity at least, to deal with issues of legacy and things that they would like to leave behind or messages or videos or even the most tangible things like a will, these are important parts of closure and ending a life well is about proper closure.
Selma Schimmel:
How important do you find the role of faith for patients and families that are facing end of life issue?
Prof. Nathan I. Cherny:
I will broaden the issue because a lot of my patients particularly who work in Jerusalem have strong religious convictions, but a lot of other people have spiritual convictions that are not related to any formal of religion. My friend and colleague, Harry Chechnov, who’s a wonderful psycho-oncologist have been researching issues related to what those people give the desire to live, people living with terminal illnesses. And the most important predictors of desire to live aren’t physical comfort or pain or things like that. It seems like hope, dignity, feelings of being supported, and these sort of issues are dealing with people’s sense of meaning, sense of purpose, sense of dignity are really important to attend to. And this is why in our department we’ve developed a strong spiritual care service center, in fact. This is part of the core element of any multidisciplinary palliative care program.
Selma Schimmel:
So Professor Cherny, world economics as they are, what role do you think that is actually going to play? We know there are changes going on in the United States as it relates to our health care delivery system and palliative care, and hospice care, all of that is becoming much more visible now in our dialogue. But overall what is the connection between world economy and its impact on treatment and these kind of decisions for patients that are dealing with serious illness?
Prof. Nathan I. Cherny:
There’s a concept in medicine, which is called marginal medicine. Marginal medicine is medicine which makes very little difference to outcomes but which costs a lot of money. And I’ll give you an example. We’ve recently seen that the FDA made the brave decision to revoke the license for Avastin in the treatment of metastatic breast cancer. This was seen as a very, very controversial and somewhat bold decision but the decision was based upon the two understandings. Number one, in no study had investor been shown to lengthen the survival of anyone with metastatic breast cancer, and not only was it not improved or lengthen their survival, it didn’t even improve their quality of life. So this issue that they had shown in one study that it lengthened the progression free interval by a number of months became something which is more cosmetic than real. It wasn’t making people feel better, it wasn’t making people live longer, and yet it was costing tens of thousands of dollars, sometimes hundreds of thousands of dollars. And also they were putting some people at risk of side effects of Neovastat. So in terms of providing benefits to patients it really wasn’t doing that adequately. And it was at an enormous individual and community cost. These sort of issues and these sort of discussions are going to start to become more poignant.
The way in which the outcomes of clinical trials are published and discussed is often a real problem because often it’s misleading the people. When people read the term ‘progression free survival has increased’ for the light reader in particular it makes people feel ‘oh this makes you live longer’. But it’s inappropriate use of language. Lennon Soltz, the major GI oncologist wrote a wonderful editorial in The Journal of Clinical Oncology saying this is a misleading term, we should be using the term progression free interval. Get rid of the survival because it’s not about that. One of the things that we’re interested in doing to make the results of clinical trials more understandable is to introduce a grading system for the degree of likely clinical benefit. So this is to say the treatments that improve overall survival these are the treatments that have major clinical benefit. Treatments that don’t improve overall survival but can improve quality of life, or median survival by more than a couple of months, we would call these having substantial clinical benefit. Treatments that improve average survival by a couple of weeks to less than two months you can’t call this a major breakthrough. And telling patients that they need to spend tens of thousands of dollars, or their insurers, for that small amount of benefit may actually be misleading.
Selma Schimmel:
So what do you tell the patient that says my daughter’s wedding is in six weeks and I want to try and do anything I can to hang on to that occasion?
Prof. Nathan I. Cherny:
Everyone’s targets are different, and this is the issue about individualized medicine. And I always tell them we’ll do everything we can to get you to there but understand that our tools are limited. But we will do our very best. You know, take away the target, take away the target and if you have an uninsured patient who says ‘is there anything more that you can give me?’ and this is now second line treatment with cancer of the pancreas. Do I really want to tell them they should be taking Tarceva, which can increase their median survival by two weeks? That Tarceva will cost them their entire family income for months until they die. Is that fair? Is that fair to a patient? Is that fair to the family legacy?
Selma Schimmel:
Yeah, but by putting the option on the table what you just did is you gave someone choice.
Prof. Nathan I. Cherny:
I won’t tell people there’s no choice when there is. But when I put an option on the table I think I need to contextualize it to say in a very honest and direct way that this is really not likely to make any difference to their overall survival and well-being.
Selma Schimmel:
You work within a very select area of oncology and medicine in general. How did you land up in this particular area as a clinician?
Prof. Nathan I. Cherny:
It’s a complex story. Number one is I grew up in a house where my father was a family doctor who did a lot of his own terminal care and my mother taught communication skills. And so the issue of both commitment to patients and commitment to communication were the things that I grew up in. Secondly when I was a first year medical student, at the end of the year, I developed testicular cancer, which metastasized to the lung, and this was really at the cusp where plucking had just been introduced into practice. So I always really was one of the beneficiaries of the first generation of Larry Einhorn’s work on testicular cancer, which changed the long term survival for testicular cancer from 25% to 95%. Thirdly, I had a thoracotomy to remove the remnants of metastasis. And from that experience I learned the importance of treating pain because getting injection of Pethidine every four hours didn’t cut it. Fourthly along the line I was very influenced by the early works of Elizabeth Carver Ross and the contribution that one can make the lives of people with an incurable illness. And so all of these things together guided me along this path, and I wanted to go into an area of medicine where I would be at the cusp between medicine, psychology, and ethics. And this is where I found myself.
Selma Schimmel:
Well I’m very moved. I didn’t know any of this about you, and when a physician also speaks out and says ‘oh by the way I’m also a survivor’ that for the patient, even knowing that, it puts you in a whole different category in the way the patient relates to you. I really want to thank you for being that open. I understand a lot more now, and I really thank you for sharing that.
Prof. Nathan I. Cherny:
It’s a pleasure, yeah. I’ve been on public record about this now. I’ve written about my experience of having been a patient and often when patients are facing tough decisions, I tell them ‘look, I’ve been on your side of the desk, and I know what it feels like to be having to be thinking about and dealing with these options’. And as I say, that is a tool that you don’t need to have that to be able to be an effective communicator but it’s sometimes it can be an important key to help people get passed difficult decisions.
Selma Schimmel:
Professor Doctor Nathan Cherny, I hope we get to do this a lot more with you together. Thank you so much.
Prof. Nathan I. Cherny:
It’s a pleasure.
END OF VIDEO