December, 2013

Rules of Engagement

By Michael J. Katin, MD

Warning: This article may contain authentic scientific references. Reader discretion is advised.

When I was in college, that institution decided to adopt a pass-fail program for a limited number of electives outside a student's main field of study, in order to encourage diversity of interest. At that time, getting into medical school was of prime importance but I appreciated this initiative and signed up to take Sociology 10: Marriage and the Family.

This was an exercise in the study of interpersonal relationships throughout the world, ranging from matriarchal to patriarchal, polygynous to polyandrous, and polyester to polyglottery. Although this was an interesting diversion I went along with the spirit of this new system and knew it was not expected that I put the same effort into writing papers or extra credit projects that I would for organic chemistry. At the end of the semester I was given a grade instead of a pass, and needed to waste time making multiple visits to the registrar's office to get it straightened out (disclaimer: if I had been given an "A" I would have gone with the flow). Due to this experience I learned two things: 1. Academic institutions will mess things up, given the slightest opportunity; and, 2. Nobody truly knows anything about relationships between and among humans.

Quite unexpectedly, years later this topic has again surfaced. The Harvard Radiation Oncology program has made outstanding contributions to the world of science, but now Ayal Aizer and his associates have published the blockbuster document of the past decade: Marital Status and Survival in Patients With Cancer.

To put this into perspective, a multitude of other articles in this time period have looked at ways to optimize results in cancer care and totally missed the proverbial boat. The International Journal of Radiation Oncology, Biology and Physics issue of November 1 included a long article, How Radiation Oncologists Evaluate and Incorporate Life Expectancy Estimates Into the Treatment of Palliative Cancer Patients: A Survey-Based Study (very interestingly, also primarily from the Harvard program) plus an editorial on Radiation Oncologists, Mortality, and Treatment Choices. It must be emphasized that this very same issue contains a brief report on Correlation of Smad4 Status With Outcomes in patients receiving Erlotinib Combined With Adjuvant Chemoradiation and Chemotherapy after resection for Pancreatic Adenocarcinoma (overall survival 24.4 months with intact Smad4 status versus 18.3 months with loss of Smad4, cure rate = ?) and an article on Effects of Respiratory Motion on Passively Scattered Proton Therapy Versus Intensity Modulated Photon Therapy for Stage III Lung Cancer: Are Proton Plans More Sensitive to Breathing Motion?? (cure rate = ?). Why is it that earlier in that very same issue radiation oncologists are being criticized for not being more realistic about patient survival lengths when making decisions on treatment (actually, 67% of estimates by physicians were higher than the prognostic model had predicted!)? Although this may be an attempt to proactively put restrictions on our practice before somebody else imposes them, I can't imagine ASCO denouncing the use of a fourth-line regimen for treatment of metastatic renal cell carcinoma.

In any event, in this article and editorial on inaccurate patient survival estimates, there is no reference whatever to marital status. Similarly, in the November 10 issue of the Journal of Clinical Oncology -- nine days after Dr. Aizer's landmark article -- there is a "Special Article" on Delivering High-Quality and Affordable Care Throughout the Cancer Care Continuum. It was gratifying that there was only one paragraph criticizing radiation oncology. However, that was one more paragraph than addressed the role of marital status in cancer care! As if that weren't enough, the November 13 issue of the Journal of the American Medical Association featured a huge article on "The Anatomy of Health Care in the United States," as well as a "viewpoint " by Ezekiel Emanuel, "Going To the Moon in Health Care: Medicine's Big Hairy Audacious Goal (BHAG)." (I'm not making this up). Dr. Emanuel's recommendation is to limit per capital cost growth in health care to GDP + 0% by 2020 -- this not allowing for technological breakthroughs and the expected increased cost by having sick people live longer. In any event, in not one of these articles is there a single reference to marital status!!

Dr. Azar's undoubted future Nobel-prize-winning study reveals that no matter what else is done -- IMRT, protein kinase inhibitors, proton beam therapy, B-RAF enzyme inhibitors, nanoparticles, robotic surgery, hyperthermia, or whatever -- being married ultimately leads to longer overall survival.

An editorial by David W. Kissane attempts to provide explanations as to why this should be the case, with the conclusion that "we are tribal people, drawn into contact with one another to share in what is most meaningful and fulfilling in life." Although this may explain why being married may help for the few people who are compatible and blissful, what about the many couples in which each actively wishes for the worst to happen to the other? It seems to be that the fact of being married is important regardless of the quality. It certainly gives new meaning to the phrase, "till death do you part."

And if being married, even if it's affection-free, or even unconsummated, may exert a beneficial effect on survival, maybe it's time to add one more ancillary service to freestanding cancer centers.