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Balancing risks and benefits
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One of the hardest parts about caring for patients with malignant hematologic diseases is knowing when to initiate treatment and how intense the treatment needs to be.
Guidelines have been developed for the diagnosis, staging and treatment of most diseases, often tailored to prognostic indices when these are available. Despite the guidelines, these decisions always should come down to a careful assessment of individual patient characteristics and preferences.
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At the beginning of my fellowship, as a physician with some experience in internal medicine but none in clinical oncology, my inclination was to treat diseases early and aggressively, usually with the newest drugs available. With time, I’ve learned to adjust this approach.
When less is more
A few weeks ago, in my malignant hematology clinic, I saw a patient, Ms. B, whom I’d originally met several years ago. She was in her 80s, with a new diagnosis of chronic lymphocytic leukemia. Early on, we opted for a course of observation — she seemed to be asymptomatic, with no immediate indications for treatment. She had long-standing chronic obstructive pulmonary disease and some fatigue related to this, but not worsening and not (apparently) disease-related.
During the months and years, I watched Ms. B’s white blood count slowly rise — past 75,000, then 100,000, and then 150,000. We had several conversations in which Ms. B expressed her desire to continue to delay treatment, although it seemed eventually that she was exhibiting some systemic symptoms that, this time, were part of her CLL. After a lot of back and forth about various choices, we settled on a course of single-agent oral chlorambucil, following the lead of the recent Blood paper that showed this approach to be no worse than fludarabine in a cohort of elderly German patients.
It’s only been a few months, but Ms. B’s white blood count is now 7,000, with normal hemoglobin and platelet counts. She feels well and has had no side effects from her treatment. Thus far, observation and a minimalist approach using an older medication seem to have served her well.
First transplant conversation
Sometime after this, I had my first bone marrow transplant clinic. This was an intimidating experience. Although I have had many of these types of conversations with patients before, there was something about having my first transplant conversation with a patient without attending precepting that gave me some additional pause for thought. This person, Ms. F, was in her mid-50s with a new, symptomatic diagnosis of chronic idiopathic myelofibrosis. I applied the usual prognostic scoring systems, including the newest international prognostic scoring system, and found her to have “low risk” (or at worst, “low-intermediate” risk) disease. But what exactly did this mean for a younger, healthy woman with an incurable disease, who was already experiencing disease-related symptoms?
We talked about the role and possible timing of transplantation, with my discussion informed by a relatively small and rapidly changing body of literature around transplant for this condition. We also talked about nontransplant-based therapies, none of which had a particularly long or impressive track record in the treatment of this disease. I had some general ideas and the outlines of a plan, but in the end, it was hard for me as a third party to accurately assess and apply the complex decision-making rules, values and preferences of this particular patient whom I’d not met prior to that afternoon.
I knew that each sentence I conveyed, whether about response rates to medical therapy, the usual procedures around an allogeneic transplant or the risks of transplant-related complications, including graft-versus-host disease and even treatment-related mortality, was difficult to understand and loaded with meaning for Ms. F. In this situation, for a variety of reasons, we elected to pursue HLA-typing and a trial of treatment with lenalidomide and prednisone and to readdress the transplant decision periodically in the coming months as we both gained a better sense of the responsiveness and tempo of her underlying disease.
I am only a month into my new life as an attending. Many of the feelings I had as a fellow are still with me, but intensified. To practice clinical oncology and hematology and to seek to understand and integrate the worldviews of our patients into our clinical decision-making are a great challenge and a tremendous privilege.
Eichhorst BF. Blood. 2009;114:3382-3391.
One of my favorite aphorisms provided to new Hem/Onc Fellows is, ‘Don’t just do something, stand there. Rescue fantasies are to be challenged with all your might.’ Dr. Wood has been taught well, methinks.
–Harry S. Jacob, MD
HemOnc Today Chief Medical Editor