March, 2018

Worry Worth

By Michael J. Katin, MD

It seems as if the specialty of Radiation Oncology continues to rank well below Rodney Dangerfield in terms of getting respect. It's bad enough that people in general are afraid of radioactivity (for which there is absolutely no basis in fact, but we just can't seem to get the attention of the public the way robotic surgery, despite the exaggerated claims, and personalized systemic therapy have been able to accomplish. Even when there are advancements in our techniques, the details are usually misrepresented and don't ever seem to acquire enough glamor to get us any additional points. Interest in proton therapy now seems to be losing momentum, and, when most physicians don't know the difference between Cobalt-60 and high-energy x-ray therapy, nobody seems to care if one has the latest model linear accelerator.

But sometimes when one least expects it, a breakthrough can occur that would never have been anticipated. For the first time in years, radiation therapy may have the opportunity to be viewed as the kinder, gentler alternative to other modalities, and all thanks to developments that would normally have been anticipated with trepidation.

Sometimes you never know who your true friends will turn out to be. Ever since the authorities had decided to measure quality indicators there has been concern that other trivial factors, such as cure rates, will be overwhelmed by patient satisfaction scores. In fact, this is a tribute to the fact that many diseases we treat can have good outcomes and now it's time to pay attention to factors that keep patients as happy as possible. A publication by the Institute of Medicine in 2008, "Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs," addressed the problem that cancer patients psychological problems were usually not being considered by practitioners and it was necessary to do this to take care of the whole person. A 2014 analysis, by Anja Mehnert et al. determined that about one out of three patients had depression, as defined by DSM criteria (at least in Germany, where the study was done. The question was then which method of assessment was appropriate to identify patients who would benefit from intervention to make their experience as tolerable as possible? This was attempted to be answered by NRG (previously RTOG) Trial 0841. This compared four different distress screening tools and settled that the PHQ-2 was the method best adapted to finding patients in need of psychosocial assistance. The PHQ-2 consists of two items: how often do you have little interest in doing things, and how often do you feel down, depressed, or hopeless. At least it wouldn't take too long to administer this.

When approval of treatment and third-party payer coverage of treatment options become more complicated, as will be the case as efforts are continued to bring down the cost of medical care, any treatments that demonstrate a benefit in quality of life, or at least to show bureaucratic efforts to quantitate quality, rather than results alone, may get priority. This being the case, it will be helpful to our cause to rally support for a parameter that has been mentioned in most of the reviews on psychosocial screening.

An article in the Journal of Clinical Oncology in 2018 by Young Chandler et al. from the Lombardi Comprehensive Cancer Center thoroughly reviewed all the factors involved in whether gene expression profile testing should be offered in community practice. Among all the considerations was the factor of "Worry," valued at -0.05 Quality Adjusted Life Year (QALY ) per year. "Reassurance" was valued at, appropriately, +0.05 QALY per year. I would like to think that the designation of these factors as being significant has opened the door to our being able to secure our specialty's survival.

Needless to say, there is more than one scale for assessing "worry," including the Lerman Cancer Worry Scale and the Penn State Worry Questionnaire, among others. The NCCN includes Distress Management among its Clinical Practice Guidelines.

Needless to say, "worry" is a relative term. I worry whether something gets delivered in the mail to the office on Friday and nobody notices it until Monday. Other people worry that in the event of nuclear war whether Netflix will still be available. From now on, we need to assess what worries patients that are making decisions for cancer treatment, since the value of worrying has been established!

For example, when decisions are to be made regarding treatment of prostate cancer with radiation therapy versus surgery, would it not be appropriate to present to a patient the following concerns about surgery: What if the surgeon may have had a particularly bad night and is not able to concentrate on the procedure? What if the surgical staff had been careless in sterilizing equipment? What if there is an electrical failure halfway during the case? What if the anesthesiologist misreads the syringes? When this is a one-time procedure, everything hinges on everything going right. With radiation therapy, with shiny expensive equipment, run with redundant back up computers and with a veritable army of highly-trained professionals involved, even in the improbable case that one treatment is messed up there are many more that will almost certainly be done accurately. Not to mention that whole thing about dribbling and decreased potency which can result from surgery and even if it occurs with radiation therapy won't happen right away and can always be blamed on something else. No contest.

What about deciding on investigational combinations of chemotherapy for lung cancer rather than at least including radiation therapy? How do you know the combinations won't have some unexpected interaction that could turn a patient into a yak? What if hematologic tolerance isn't as good as expected, and what if all the side effects from immune checkpoint inhibitors, happen? At least radiation therapy only goes where we point it. Again, no contest.

Thank you, quality measures people. Maybe we're finally going to have some sense of security. Only problem is, I worry it won't work.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including March 1, 2018, this leaves 5,420 days to his goal.