The New York Times - 06.08.2019

THE NEW YORK TIMES, TUESDAY, AUGUST 6, 2019 N D7

AS THE ELDERLY MANwith an incurable can-
cer lay dying, he told his son he had only one
regret. Rather than enjoying his last weeks
of life with the people and places he loved,
he had squandered them on drug treat-
ments that consumed his days and made
him miserable.
Perhaps others can benefit from this
man’s end-of-life insight. Too often, people
with incurable cancers pursue therapy be-
yond any hope of benefit except perhaps to
the pockets of Big Pharma.
There are many reasons this happens.
Some patients won’t acknowledge that their
death is imminent, and some doctors won’t
admit to them that nothing more can be
done to contain the disease. Others with un-
stoppable cancers think that if they hang in
there long enough, a new treatment may
come along to reverse their fate.
And some patients hope to ward off the
Grim Reaper until after a special event. Still
others succumb to the urging of family
members to try everything modern medi-
cine can offer. Even I fell into that trap.
When my husband was nearing death
from lung cancer, I authorized radiation
treatments in hopes he could attend a con-
cert of the theater songs he had written.
Alas, this was not to be (the concert became
his memorial service), but after he died I re-
alized how much my goal tormented his last
weeks with treatments he didn’t want.
I also now realize that how people spend
their remaining days should be a personal
decision based on sound medical advice and
free from other people’s influence. This
should prevail for any ailment for which
there is no longer effective treatment, or
when the harmful effects of treatment far
outweigh any imagined benefits, or when
patients decide that their disease or its
treatments make their lives not worth liv-
ing. For example, in February, Paula Span
wrote in the New Old Age column about a
92-year-old man with failing kidneys who,
after two weeks on dialysis, discontinued
treatment because “this is not the way I
want to live — it’s painful and tiring.” He
died two weeks later.
Although slightly more than two-thirds of
cancer patients treated in the United States
are cured, this is mostly the result of early
detection and combinations of surgery, ra-

diation and chemotherapy treatments de-

veloped decades ago, Dr. Azra Raza, direc-

tor of the Myelodysplastic Syndrome Cen-

ter at Columbia University, wrote in her

forthcoming book “The First Cell, and the

Human Costs of Pursuing Cancer to the

Last.” In fact, experts suspect that some

cancers discovered through early detection

would never have become fatal even if they

had not been treated.

But once solid tumors like cancers of the

breast, colon, lung and prostate have

spread well beyond the organs where they

began — Stage 4 cancers — cure is rarely, if

ever, possible, although treatments with im-

munotherapy, for example, can sometimes

prolong lives for months or longer.

(Prospects are far better for body-wide can-

cers of the blood and lymph systems.)

At best, the often very costly treatments

available today to treat patients with far ad-

vanced Stage 4 tumors do little more than

postpone the inevitable and can make pa-

tients even more debilitated. When chemo-

therapy is used palliatively to shrink painful

tumors, it is important to know when to stop

because it is no longer helping.

As Dr. Raza wrote, most new cancer

drugs add mere months to a patient’s life at

an agonizing physical and financial cost.

For example, she noted, the drug Tarceva

prolongs survival of those with pancreatic

cancer by an average of 12 days at a cost of

$26,000 a year.

Still, buying time can be meaningful to

many patients, who may use it to get their

affairs in order, reconcile with estranged

family or friends, and say meaningful good-

byes. A brilliant young woman I knew who

died of colon cancer at 31 used the few extra

weeks of life treatment likely gave her to

finish writing an opera.

But experts who focus on quality of life

maintain that it should be up to patients to

decide if continued treatment is worth the

costs. And not just personal costs but also

dollar costs, given that some new therapies

cost hundreds of thousands of dollars a

year. Furthermore, these experts say, the

decision to continue treatment should be

based on honest, factual advice, not wishful

thinking or pressure from family members.

The decision today is more complicated

that in decades past because some modern

treatments are less toxic than traditional

chemotherapy and because there are now

ways to counter, though not necessarily

eliminate, the devastating side effects of

many treatments. Medical centers, the me-

dia and the internet contribute to treatment

dilemmas by touting early promising re-

sults of new therapies, giving patients and

their families renewed hope for survival.

I wonder, too, how often oncologists sug-

gest an experimental treatment more for

the benefit of science than for the patients

they’re treating. Based on my family’s ex-

perience, honesty about the goal is the best

policy.

In 1958 when my mother was dying of

ovarian cancer, her much admired and

forthright oncologist, Dr. David A. Karnof-

sky, who devised a scale to assess patients’

ability to survive chemotherapy, told my fa-

ther that there were no other treatments to

help her. But the doctor asked whether

some experimental drugs could be tried

that might prove beneficial to patients with

less advanced disease.

Even when people with advanced cancer

are relatively healthy, attempting yet an-

other round of treatment often worsens

quality of life in their final weeks, according

to a 2015 study of 312 patients with meta-

static solid tumors and a prognosis of six

months or less to live.

About half the patients in this study opted

for end-stage chemotherapy. For those who

were sickest at the start, quality of life in

their last week was no worse than if they

had skipped further treatment. But among

the 122 patients in the best shape initially,

quality of life was significantly worse for the

56 percent who opted for further chemo-

therapy. Holly G. Prigerson of Weill Cornell

Medical College, who directed the study, ex-

pected the healthier patients to do better

and was surprised by the results.

As Dr. Charles D. Blanke wrote about the

study, published in JAMA Oncology, “Che-

motherapy is supposed to either help peo-

ple live better or help them live longer, and

this study showed that chemotherapy did

neither.”

Sometimes, however, chemotherapy or

radiation is offered to patients near the end

of life to alleviate debilitating symptoms.

But the goal of such palliative therapy

should be made clear to patients lest it give

them false hopes for a cure.

Treating Cancer at the End of Life

When it comes to Stage 4

tumors, honesty about the goal

of therapy is the best policy.

GRACIA LAM

How people spend

their remaining days

should be a personal

decision based on

sound medical advice

and free from other

people’s influence.

PERSONAL HEALTH JANE E. BRODY

We l l

What Everyone Should Know About ACL Surgery

Choosing the right treatment option for an ACL tear upfront can have lifelong implications. On behalf of Hospital for Special Surgery, the world’s largest academic

medical center specializing in musculoskeletal health, we the surgeons of the HSS Sports Medicine Institute have drafted the following guidelines for people who are

considering ACL treatment.

Reconstruction is the current standard of care surgical treatment for tears of the anterior cruciate ligament (ACL). This procedure typically uses a graft, or a piece

of tissue, placed in the knee minimally invasively, using small incisions. About 300,000 ACL reconstructions are performed annually in the United States with well

documented rates of success.

ACL repair is an older technique that involved suturing (sewing) torn ACL tissue, not rebuilding it with a graft. ACL repair was performed in the 1970s at select

institutions, including Hospital for Special Surgery, but was abandoned due to unacceptably high failure rates of up to 50%.

Today, ACL repair has been modernized and can be performed through a minimally invasive approach. Proponents suggest that modern ACL repair techniques may be

performed safely and may lead to a quicker recovery than ACL reconstruction. However, the limited studies to date raise questions that must be discussed in detail with

your surgeon.

1. It is critically important to get ACL surgery right the first time.

When ACL surgery fails, surgeons must do a revision procedure to correct or revise the problems that were not fully addressed the first time. Revision requires

reconstructive ACL surgery with a graft. (ACL repairs cannot be done as revisions.) Redoing ACL surgery may result in higher rates of failure, lower rates of return to

sports, and increased risk of osteoarthritis.

The importance of successful initial ACL surgery holds true for people of all ages, but it is particularly critical for young athletes, for whom a failed surgery can have

devastating consequences, including years lost from sport in the short term as well as chronic pain and loss of function in the long term.

2. Failure rates for ACL repair appear to be significantly higher than those for ACL reconstruction in people of all ages.

Current studies suggest that modern ACL repair techniques have a failure rate that may be five to ten times higher than that of ACL reconstruction. One major

recent study in a prominent sports medicine journal found that arthroscopic ACL repair has unacceptable outcomes in young athletes, with short-term failure rates

of close to 50%.

It has been suggested that ACL repair may be appropriate for older adults who have a type of ACL tear called a proximal avulsion and who do not participate in “cutting

and pivoting” sports such as basketball, volleyball, and soccer. For these patients, failure rates in the short term appear to be much higher than ACL reconstruction in

this age group.

3. There is still much we don’t know about ACL repair.

There has been no scientific evidence that shows a difference in postoperative pain between ACL repair and reconstruction. Rehabilitation and return-to-play protocols

for ACL repair have not yet been established. Proper guidelines for rehabilitation and return to sports are essential to keep people safe from re-injury.

For more information visit hss.edu/acl

Answorth A. Allen, MD

David W. Altchek, MD

Struan H. Coleman, MD, PhD

Frank A. Cordasco, MD, MS

David M. Dines, MD

Joshua S. Dines, MD

Stephen Fealy, MD

Andreas H. Gomoll, MD

Lawrence V. Gulotta, MD

Jo A. Hannafin, MD, PhD

Anne M. Kelly, MD

John D. MacGillivray, MD

Robert G. Marx, MD, MSc, FRCSC

Michael J. Maynard, MD

Moira M. McCarthy, MD

Danyal H. Nawabi, MD, FRCS

Stephen J. O’Brien, MD, MBA

Anil S. Ranawat, MD

Scott A. Rodeo, MD

Howard Anthony Rose, MD

Beth E. Shubin Stein, MD

Sabrina M. Strickland, MD

Karen M. Sutton, MD

Samuel A. Taylor, MD

Russell F. Warren, MD

Thomas L. Wickiewicz, MD

Riley J. Williams III, MD

Andrew D. Pearle, MD Bryan T. Kelly, MD

Chief, HSS Sports Medicine Institute HSS Surgeon-in-Chief and Medical Director