Decision Making In Cancer Treatment – One Size Does Not Fit All

In the current era of multi-modal cancer therapy, designing a personalized treatment plan for cancer is challenging. Patients, their families, and oncologists have to contend with a multitude of factors. These factors come under three categories – disease factors, patient factors, and environmental factors.

  1. Disease factors: the primary site of cancer, stage at diagnosis, type of cancer (based on histopathology, immunohistochemistry, molecular typing, genetic studies, etc), any previous treatment received, etc.
  2. Patient factors: age, general health condition, other co-existing illnesses, etc.
  3. Environmental factors: healthcare resources available, financial constraints, family and social support, advances in treatment, etc.

The first of these, disease factors, are perhaps the easiest to determine. Clinical, radiological, and pathological evaluations that determine disease factors are relatively straightforward to interpret. Medical literature is also simpler to interpret in the context of disease factors. In fact, many patients and caregivers look up online resources and develop a reasonable understanding of the treatment process (“stage 3 colon cancer should be treated with surgery followed by adjuvant chemotherapy”).

The second set of factors, patient factors, are much more subtle. At age 78, one person may be very fit and active, another quite frail – both may not be able to receive the same treatment even if disease factors are the same. If someone has had a recent heart attack and has multiple other major health conditions, should we perform a potentially curable but very risky major cancer surgery? How easy is it to assess these patient factors within a few hospital visits? In addition to taking opinions from our colleagues in other disciplines of medicine (cardiologists, pulmonologists, etc), we also utilize other tools that help us assess these factors (performance indices, life expectancy tables,etc).

The third set of factors, environmental factors, are equally important. In India, with limited insurance penetration, and huge out-of-pocket expenses, costs are a major deterrent to accessing healthcare resources. How much of one’s life savings can one spend on a treatment which will increase cure rates by, say, 5%? Is it logistically feasible to move to a different city for six months for a treatment program not available in one’s own hometown? What are the alternatives?

To come up with the most optimal cancer treatment program for an individual, all of these factors must be considered. What is best suited for one person may be completely different for another.


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