Friday, January 01, 2010

Chemo according to Freakonomics

I was excited to learn that Freakonomics authors Steven D. Levitt and Stephen J. Dubner released a follow-up: SuperFreakonomics. If you don't see how economics could ever be interesting and/or relate to your life, these books are for you. Freakonomics promised to explore the hidden side of life, answering questions like, "What do schoolteachers and Sumo wrestlers have in common?" and "Why do drug dealers still live with their moms?" The response to the book was so great that the authors began a blog to keep the conversation going. I could only imagine what the authors would unearth when they wrote SuperFreakonomics but I didn't figure it would end up relating to me or my work. Then I came upon chapter 2 "Why should suicide bombers buy life insurance?" I'm not going to let you in on how chemo relates to this intriguing question; you'll have to read it yourself.

The authors discuss how most people want to prevent death at any cost. For those of us in the palliative and hospice worlds, this is nothing new. When it comes to cancer, chemotherapy and/or radiation are givens. (Anecdotally, it seems like most people just go along with whatever the oncologist says, without doing their own research or looking at or asking about treatment outcomes.) Most pharmaceutical sales are for chemotherapy. Chemo has been proven effective for the following cancers: leukemia, lymphoma, Hodgkin's disease, and testicular, especially when detected early. However, chemo has not been proven to be effective in most other cases of cancer, per Leavitt and Dubner. (Levitt and Dubner derived much of this section from interviews with practicing oncologists and oncology researchers, as well as articles and studies.) In fact, chemo has been shown to have no discernible impact on multiple myeloma, soft-tissue sarcoma, melanoma of the skin, and pancreatic, uterine, prostate, bladder, and kidney cancers. Yet, we can probably all identify people with these types of cancer who received chemo. My Grandma had multiple myeloma and was given chemo. I remember at the time thinking it was a small world, as the form of chemo she was given was ultimately developed through money raised by The Leukemia and Lymphoma Foundation, with whom I had fundraised for the year prior. It was a newer drug so maybe the oncologist was not off-base in trying it...God knows we were all grasping at straws of hope when she was diagnosed.

According to the book, cancer patients make up 20% of Medicare cases but use 40% of the Medicare drug budget. A typical chemo regime for non-small-cell lung cancer costs over $40,000. Consider that it will extend a patient's life by an average of 2 months. For that patient and his or her family, the costs and ravages of chemo might be worth an extra 2 months. But it might not. And how many patients are told the outcome prognosis upfront? The authors ask: "Considering its expense, its frequent lack of efficacy, and its toxicity- nearly 30 percent of lung cancer patients on one protocol stopped treatment rather than live with its brutal side effects- why is chemotherapy so widely administered?" Possible reasons include profit motive (oncologists are the highest paid doctors and they make more than half of their income from selling and giving chemo drugs; the other half of their income is ostensibly through surgery and radiation) and inflating survival-rate data. Or being overconfident in the efficacy of chemo. "'If your slogan is 'We're winning the war on cancer,' that gets you press and charitable donations and money from Congress,' [Tom Smith] says. 'If your slogan is 'We're still getting our butts kicked by cancer but not was bad as we used to,' that's a different sell.'" A final reason is that oncologists are only human who have to tell other humans they are dying and that they can't do anything to stop that. This is certainly a contributing factor to why we get so many late referrals to palliative care and hospice.

Even though chemotherapy has negatives against it, the authors deliver this good news: people who would have died previously of heart disease are now living long enough to die from cancer instead. Almost 90% of new lung cancer diagnoses are over age 55, with a median age of 71. Also mortality for people age 2o and younger has fallen by more than 50% and people aged 20-40 have a decreased mortality rate by 20%. The incidence of cancer for all age groups continues to rise, however.

So what does all this mean? It's certainly something to ponder as we work with our patients, those who are considering future treatment options or those whom have been told there are no options left. It's also good to be aware if and when you yourself are diagnosed with cancer. It brings quality of life issues into a new light. And in case you didn't find this interesting or relevant at all, you might want to consider chapter 4 (The Fix in in- And it's Cheap and Simple) and chapter 5 (What Do Al Gore and Mount Pinatubo Have in Common?) on hand-hygiene compliance in healthcare settings. My kudos to Dr. Semmelweis.


Pat Killingsworth said...

Thanks for providing the info! I agree with most of it. But as a multiple myeloma survivor who is alive today because of chemotherapy, I am a bit confused by the statement chemo doesn't work on mm. I write a daily blog, where we deal with a number of chemotherapy options for mm patients, most of which work for six months to six years. When that type of chemo stops working, you try another which is also likely to work. 80-90% of mm patients respond to one of these "novel" chemotherapy agents, Thalomid, Revlimid or Velcade. I'm just saying... Pat

LeighSW said...

Hi Pat, thanks for your comment and for letting me know about your blog. I'm glad that chemo was effective for you! I'm not sure which specific studies the authors drew from regarding the cancers that do not respond as well to chemo (the works cited is on p. 234-5) so it could be that chemo is less effective on more advanced stages of those cancers or that certain types of chemo are less effective. My Grandma took Velcade with little effect. I'm glad there are good options out there for those currently with MM.