Emeritus Professors and Rationing of Cancer Care

One of my NP’s presented a new consult to me this week: 15cm central HCC, wheelchair bound, heart and renal failure, blistering wounds on the legs from severe edema requiring daily dressing changes and whirlpool therapy for debridement...you get the picture. She advised me not to treat him. 

I walked into the room prepared to give my death talk (translation: end of life counseling). Much to my surprise, my customer turned out to be an emeritus professor of chemistry, hard at work on his third book. His body was failing, but his mind was sharp as a tack. He observed that while he was active faculty, he was so busy with teaching and running his lab that he did not have time to write; now that he is emeritus, he can devote himself full-time to writing his books. He was very interested in not dying of his liver cancer. 

A long discussion with him and his family ensued regarding his prognosis with and without therapy in the context of his various co-morbidities, as well as the increased risk of any therapy given his multi-organ insufficiencies. His family members were clearly as bright as he is, so it was a high-level and realistic conversation, with no undue pressure exerted on the patient. In the end, the consensus was to attempt yttrium therapy, as an acceptable compromise of risk and benefit.

Of course, the judgment of what is “acceptable” has to include the treating physician. I expect many of my colleagues would have declined to offer therapy to this patient. In general I will do whatever the patient wants if I believe the benefit outweighs the risk, and their insurance covers it. This incorporates my own judgement as to how safely I can do procedures, including using the “Soulen kick-out” technique to do a complete visceral arteriogram with 12 ml of contrast.

I have another emeritus professor who I treat for metastatic colon cancer. He is 91 years old. His goal is to finish the 6th volume of his definitive treatise on Latin American history. Unlike the first patient, he still walks 2 miles and does 100 sit-ups daily, so the decision to treat him was a little more straightforward. He is very grateful for being alive and disease-free for the time being.

I recently treated a 92 year old woman with HCC who multiple other physicians had declined to offer therapy. After a combined chemoembolization + RFA of her 5cm tumor, which she sailed through without turning a hair, she is also disease free and remains active in her church. She told me that I was the only doctor who did not mention her age during the consultation. She prays for me every week.

Another patient of mine with renal cell carcinoma weighs 450 pounds. He was despondent after several doctors refused to treat him because of his morbid obesity. I calculated that I could hub a 20cm cryoprobe and just fit him into our large-bore cardiac CT scanner. He too is disease free. 

Extremes of age and comorbidities pose interesting dilemmas in decisions regarding cancer care, and defy simplistic rationing strategies. If we don’t keep the emeritus professors around, who will write the books?

1 Comment
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March 20, 2013 05:50 AM by Ginna


You truly are an oncologist sometimes :)

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