June 10, 2011

Meet the patients who refuse cancer treatment

Daily Briefing

Time magazine recently examined why a "small minority" of patients choose to forgo cancer treatment even though it could prolong or save their lives.

"Refusenik" patients—as Time dubbed them—are a distinct phenomenon from patients who decline end-of-life care. Instead, these patients typically make the decision to forgo care soon after diagnosis, and the treatments they refuse could cure or control the disease. Although media reports have highlighted religious reasons for refusing care, most refuseniks do not base their choice on religion or mistrust of modern medicine. For example, Time notes that many of these patients will undergo surgery, but then forgo subsequent chemotherapy or radiation.

According to a breast cancer activist and health journalist, for these patients "unlike most drugs, which provide the high possibility of benefit with the possibility of harm, many anticancer drugs…provide near certainty of harm with only a possibility of benefits." In addition, refuseniks may be unsure of how long harsh therapies would prolong their lives and how expensive they would be. "Survival is easy to measure, but what we don't measure is how people live during the time they are alive," the director of general surgery at the University of South Florida says.

According to Time, personality, demographics, and the type of cancer also play a role in whether patients refuse treatment. For example, older women with breast cancer are more likely to forgo treatment involving surgery, chemotherapy, or radiation. One survey found that 3% of breast cancer patients under age 65 refused treatment, compared with 7% of patients older than 65, Time reports.

A physician's dilemma
Physicians sometimes find it difficult to accept a patient's decision to go against recommended treatment, Time reports. A professor of complementary medicine at the University of Calgary says physicians often try to get patients to change their mind or try to "cover themselves in case the patient or the family later decides to sue for inadequate care." However, the professor adds, "Others take a very detached view and simply rationalize that, having given the options to the patient, they have no further responsibility."

Time notes that physicians ideally would shift conversations with patients who refuse treatment to managing the time they have left. The director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute says that the therapeutic relationship between physicians and patients coping with cancer is a significant predictor for quality of life (Davis Konigsberg, Time, 6/2).

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