Continue chemo?

November 27, 2008 3:16 PM

Should my grandmother continue chemotherapy?

My grandmother has advanced stage breast cancer, and she has the choice of whether or not to continue chemotherapy. She asked me for advice, and I was at a loss as to what to tell her. Can anyone point to any scientific papers or the like that give me some evidence one way or the other?

Would advising her to continue not be in her best interest since chemo obviously adversely affects her appetite, physical strength, and mood?

Or would her decline be greater if she were to discontinue chemo?

posted by frankie_stubbs to health & fitness (10 comments total)

To clarify a bit- her oncologist recommended she continue.
posted by frankie_stubbs at 3:20 PM on November 27, 2008

If you're looking for statistics and outlook, this might be a useful guide. But really, the best approach would probably be to go with your grandmother to the oncologist and ask as many questions as you can.
posted by le morte de bea arthur at 3:33 PM on November 27, 2008 [1 favorite has favorites]

And see another oncologist or two.
posted by jeffburdges at 3:35 PM on November 27, 2008

I'm sorry to hear you and your grandmother are going through this. My heart goes out to you, but I don't think any of us are in a position to answer this question. With advanced cancers, the decision to continue chemotherapy depends a great deal on the specific cancer, prognosis with and without therapy, and the patient's own goals of care. And none of us know these details (especially the last detail, which is perhaps most important). Rather than making a blanket statement, I would suggest finding out from her oncologist what she might expect with and without treatment, and why he thinks treatment would be beneficial. As it sounds like she's already experienced what chemotherapy is likely for her specifically, what she needs is to be better informed about what benefits the therapy may be providing so that she can make an informed (though obviously very difficult) decision. In their minds, based on the statistics and prior evidence out there, doctors are always making a generalized risk-benefit assessment when they recommend a certain therapy, but they often fail to communicate the details of this. Consequently the patient is left out in the cold when it comes to what should ultimately be a patient-centered decision on a case-by-case basis. So to reiterate, my recommendation would be to get more information. Arrange another appointment or two if needed, simply to discuss the goals of care and get more details about why the oncologist is making this recommendation. And if you're unsatisfied with that, seek out a second opinion.
posted by drpynchon at 3:38 PM on November 27, 2008 [4 favorites has favorites]

Frankie, drpynchon is absolutely right. But please consider too that your grandmother may be asking more for you to sit and listen to her, than to give her specific advice. It's just too big, scary, and permanent of a decision for her to ask you to make for her.
posted by Houstonian at 6:09 PM on November 27, 2008 [1 favorite has favorites]

Another point to consider is that sometimes chemo is recommended for palliative purposes - it may not provide a cure but may shrink a tumor providing relief from pain and other symptoms caused by the tumor. Of course this can be offset by the undesirable effects of the chemo itself. I agree with everyone else that going with your grandmother to one or more appointments would be sensible. It's hard for anyone to be in the middle of that situation and make intelligent choices while feeling overwhelmed both physically and mentally so if you can go and be another set of ears and ideas (and take notes after bringing in written questions!) you'll be giving her invaluable help.

Questions to ask might include - what are the expected benefits of continuing? Is she at a point where palliative care is appropriate? What are the negatives of continuing chemo? Likely additional problems? Possible alternative treatment regimens including other drugs, radiation or stopping? Depending on the stage of her cancer it may make sense to look at clinical trials
posted by leslies at 6:11 PM on November 27, 2008

As everyone has already said, this is a very personal decision and can vary depending on the area effected, the size of the tumor, and the purpose of the chemo. That said, if this is a terminal diagnosis, you have to consider quality of life & longevity of life and it is possible the two may contrast starkly. Chemo is a difficult thing, and can make enjoying your remaining time very difficult, if not impossible. On the other hand, forgoing chemo may involve discomfort and psychological pain.

Second (and/or third) opinions, having a very honest discussion with your grandmother of her expectations, wants and needs, and consideration of all of her options would all be very helpful. I wish we could give you one right and true answer, but unfortunately, there is none. Whatever makes sense to your grandmother, which most likely be her first instinct, is what she should do and being able to support her in that decision will be the greatest gift you can give her and your family. Good luck to her and you and the rest of your family.
posted by katemcd at 7:15 PM on November 27, 2008

I'm so sorry for you, your grandmother, and your family.

Lots of good advice here. But the best is to ask your grandmother what *she* wants--that is, what she would choose if she did not have to think about the rest of the family. When you reach the stage of palliative care--if that's what is at issue here--it can be very hard to separate what the patient wants from what his or her family wants, even for the patient. My dad went through a couple of months of nasty "palliative" care last winter. At the time, it seemed to be what he wanted, but in hindsight, I wonder how much of it was something he tolerated because he thought it was what my sister and I wanted. It didn't make his life much better, and it didn't prolong it in any meaningful way.

So my advice is to ask her what she wants, what she would decide if she had no living relatives and the decision were hers alone, as painful as that conversation may be. That's the only way you can know what to do. Her death will be no easier for you to take if it's postponed for a few months. But it might be easier for her to endure if it comes sooner. If the cancer is terminal, that's the decision she is facing.

Good luck.
posted by brianogilvie at 8:10 PM on November 27, 2008

offer to talk to your grandmother's doctor. make sure she lets her doctor know that it's okay to discuss her case with you--she may have to sign a waiver. the doctor may be more willing to tell you whether or not her cancer is terminal--ask the doctor bluntly why they recommend continuing chemo--because there's a chance of remission, or for palliative purposes. in either case, she should get a second opinion. if it's for remission purposes, talk to another oncologist--sometimes doctors are reluctant to let their terminal patients "give up" because it makes them feel like they've failed. another oncologist may be able to help you make sense of the odds. if for palliative purposes, absolutely speak to a palliative care doctor. your hospital's hospice program should be able to recommend something. there may be other options that may be more comfortable. in fact, she may want to talk to a hospice expert regardless--they can let her know what options are available if she chooses not to continue, and that will make it less scary.

to me, it sounds like she is asking your permission to discontinue therapy--if she really was gung ho about it, she wouldn't be asking you. she wants to know if she can "give up" without feeling guilty.
posted by thinkingwoman at 8:01 AM on November 28, 2008

Lots of good advice here. I agree that you should go with her to the oncologist and ask her to give the doctor permission to discuss her ongoing care with you. My father has stage 4 cancer and I've found that his doctors are more than willing to answer all of my questions. My father doesn't ask any questions, which I understand can be fairly common with people who have a terminal or very advanced diagnosis - it can be very tough to hear.

Ask the doctor what the reasons are for continuing the chemotherapy - as mentioned above, is it therapeutic (are they trying to get her into remission, or trying to reduce the tumor load in anticipation of surgery to remove tumors?) or palliative (are they trying to reduce the size of the tumors to provide symptom relief)? Definitely get a second opinion and discuss all the options with each oncologist. Also discuss this with your grandmother - she may not want to pursue an aggressive treatment plan because the side effects outweigh the benefits, and that is her choice. She may feel like utter crap from the chemo and want to discontinue so she can live out the rest of her life in relative comfort, and she may be seeking your approval. Some patients will continue chemo or other therapies even though they don't want to because they don't want their family members to be upset.

I agree with thinkingwoman on consulting with a hospice expert - even if your grandmother is not a candidate for hospice at this time, they will be able to give you information about what to expect and how to make her life as comfortable as possible. My father has hospice involved and they are great - and when his condition improved (he was bedridden and stopped chemo, now he is walking around again and ready to resume treatment) they were very helpful in getting him physical therapy.

Good luck and I wish the best for you and your grandmother. Your love and support will go a long way to help her.
posted by bedhead at 10:41 AM on November 28, 2008