Personalized Treatment Planning: A Physician’s Perspective

Jeffery A. Meyerhardt, MD, MPH

In this issue of Conquering the Cancer Care Continuum, Ms Faiman and Dr Stricker focus on aspects of treatment planning in cancer patients. While they come at the topic from slightly different angles, both cases illustrate that deciding on whether to treat patients, which drugs to use, and what other supportive medications to consider is not a simple cookbook process. In this commentary, I will provide a perspective on my conversations with patients and then discuss some pressing issues that are emerging in this area.

As a medical oncologist, consideration of cancer-directed therapies needs to be a discussion with the patient and family/friends (if the patient chooses to involve others). Even though guidelines help direct choice of drugs based on a patient’s disease and stage, all of these conversations need to include an option of not choosing treatment (at least treatment directly at the cancer, ie, chemotherapy). While FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) would be the standard therapy for a patient with stage III colon cancer, it is still the patient’s option to receive any treatment. My personal style is to discuss not receiving chemotherapy first and then go back to it at the end. My rationale is that although we are starting to make advances in personalized medicine, ultimately we cannot definitively predict which patients will benefit from a given therapy and what degree of toxicities they will experience. Thus, there is no chemotherapy that I am aware of that is 100% guaranteed to help every patient with that cancer type and stage. As such, on an individual patient level, there is the potential that a treatment will cause more harm (toxicity) than benefit. Next, as I discuss treatment options, one needs to be cautious both on how to interpret clinical trials and how to communicate such results to patients. For example, if I discuss the advantage of one chemotherapy regimen (regimen A) to another regimen (regimen B) as first-line therapy for pancreatic cancer, it is neither accurate nor helpful to a patient to state that regimen B will increase your survival by 4 months. In reality, regimen B may not result in 1 day more of survival for that patient, or it may result in 1 or more extra years of life. Unfortunately, we do not know how to definitively determine who benefits and who does not, and for how long. While these conversations should not become lessons in epidemiology and statistics, they do need to convey a level of understanding of what an improvement of 4 months means. Lastly, discussion of potential toxicities and potential ways to manage them is key in helping a patient decide on a therapy choice; however, again, providing a sense of the variability in tolerance is important. I believe these conversations should be a team effort (potentially including the oncologist, nurse practitioner, physician assistant, nurse navigator, infusion nurse, pharmacist, etc) and should not be done in just one sitting. Further, I emphasize to patients that these are fluid conversations, and reassessment of tolerance and activity regularly are necessary to balance quality of life with efficacy.

While such an approach is my typical practice, several growing forces are important to discuss. Ms Faiman brought forth one of them in her case of the patient considering cost when choosing not to treat his myelodysplastic syndrome. Unfortunately, and to many of us, tragically, the cost of cancer therapies continues to rise with each new drug approved. Cancer treatment comprises 5% of the overall healthcare costs. Total costs have doubled in the past 20 years, although overall healthcare costs have also doubled. We have drugs that could cost someone (the patient, the insurer, or both) at least $100,000 per year – double the median income in the United States. Realize that is the cost of 1 drug alone, not including the rest of the care for that patient. Until recently, cost was never or rarely in the conversation regarding cancer care. Increasingly, it needs to be integral to the conversation. However, it needs to be integral in an informed way, but unfortunately we are still limited on how best to do that. Going back to my example of pancreatic cancer, let’s assume regimen B costs twice as much as regimen A, and the improvement in median survival is 4 months. Is 4 months worth double the costs? Obviously, an immediate question is what are the costs – $1 versus $2 is not so bad; $15,000 versus $30,000 is more substantial. Again, median survivals do not speak to an individual patient, and we need to know which patients gain an extra year or 2 of life, where double the cost may be more reasonable, and which patients gain only a week of life where double the cost may not be reasonable. Along with this concept, both Ms Faiman and Dr Stricker cite National Comprehensive Cancer Network (NCCN) Guidelines to help make treatment choices. The issue with these and many other guidelines and compendiums is that often many choices are provided. In the case of metastatic breast cancer, the NCCN provides more than 35 chemotherapy options after hormonal therapy. However, the financial costs of these regimens vary greatly. While not all the regimens have similar efficacy or are appropriate for every patient with that condition, there are usually multiple regimens that one could consider that have a similar likelihood of benefit for a patient. Thus, cost probably should be added into the equation regarding treatment planning. While I am not sure what the best way is to integrate into guidelines both efficacy, toxicities, personalization, and costs, I am confident we need to figure it out soon.

In summary, treatment planning is a key to the care of our cancer patients. Treatment planning is not simply going to a book or guideline and picking a regimen off a list. Planning requires consideration of the patient’s condition, patient’s goals, risk of therapy, potential benefit, and costs.

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