Thursday, April 3, 2008

Risks

Every day we take risks, we drive, we invest in the stock market, we apply for jobs, risky business life is eh?

The vernacular of medical oncology is risk. Local radiation is a treatment to reduce the risk of recurrence of the cancer in the breast Chemotherapy helps to reduce the risk of recurrence of cancer in other parts of the body, it also helps to improve 10 year survival rates. Hormonal therapy reduces risks in similar fashion if the tumor feeds off female hormones.

We know about the benefits of these therapies thanks to clinical trials that have randomized, quantified, stratified up the yinyang.

I think one of the hardest tasks of an oncologist is communicating the risk reduction of treatment to a patient. It's essential that the woman with breast cancer understands her options and understands the benefits of such options, but when the data is so complex, when the benefits are blurred, effectively communicating the concept of risk is crucial to ensure shared decision-making.

So far I've only discussed the risks reduced by treatments for breast cancer. To make things more tangled for treating breast cancer, there are also risks associated with the very same treatments that help fight the tumor. Radiating vital organs, Heart failure caused by adriamycin, uterine cancer from tamoxifen, you have the potential of getting ANOTHER cancer from an anti-cancer treatment. How dumbfounding! So here comes the second layer of risks and benefits for treating cancer. The oncologist and the patient have to weigh the benefits of treatment with the additional risks taken on due to such treatment. Here's a question, if someone told you that you could take a drug for 6 months, lose your hair, feel sick all the time, lose feeling in your fingers, have no energy, and this drug would improve reduce your risk of recurrence of cancer by 10%. But, this same drug comes with a risk of heart failure, say 4%. Getting complicated yet?

The tertiary level of complication is the basis of all of these numbers, where did all these numbers come from anyways? We know the answer: clinical trials. But the deeper questions are, what types of patients were on the trials? Were they your age? Were they your ethnicity? Were their tumors similiar to your tumors? Where they node-positive patients? Node-negative patients? How far along did they start the treatment? Did they take anything to prevent breast cancer in the first place? How successful was the local resection? What other treatments did they have? Talk about opening Pandora's Box...

Given this uncertainty, how are oncologists (or patients my gosh) supposed to make sense of all of this? That's my question, I still haven't figured out the answer. For oncologists, I know that years of training, of questioning and contributing to the medical literature, of immersing themselves in the controversies and successes of medical oncology, and treating a lot of patients can help. For patients, I think it comes down to the realization that at a certain point, you have to trust your physician's judgment, you have to believe in the efficacy of your treatment, and you have to have a lot of hope.

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