Palliative versus curative care.

This is an important distinction: palliative versus curative cancer care. There is no simplistic definition for palliative as it is understood in cancer management. But it is at a minimum, treatment (medical or surgical) that aims to keep a disease process and its symptoms and signs from getting worse. So, stabilizing an enlarging pulmonary mass that is encroaching on major airways and producing post obstructive pneumonia would be a proper goal of palliative cancer care in the setting of a patient with a primary lung cancer whose spread of the cancer is limited to the thorax. It would take two to three monthly cycles of combination chemotherapy and a course of radiation therapy to accomplish the goal.

What would this accomplish? The patient would feel better because the pneumonia would resolve. He or she would not feel worse for the fact that the cancer grew to obstruct major airways and caused loss of major portions of otherwise functional lung tissue. There would be side effects from the chemotherapy, some of them ameliorated by other drugs; and there would be side effects from the radiation therapy. There would be the stress of coming and going to clinics. And there would be the expenses of treatment and transportation. And all of this would be set against a backdrop of knowing that the problem(s) have no permanent solution--so a gnawing sense of futility balanced against a hopefulness engendered by the "therapeutic milieu."

Would there be improvement in the difficult to define but easy to feel "quality of life?" Definitely yes--otherwise there would have been no reason to do the intervention.

Would there be improvement in the easy to define "length of life?" No. By definition incurable diseases have no cure and palliative care that is given in the setting of incurable (here malignant) disease does not prolong life. Note that there are exceptions to every rule and errors inherent in any staging procedure so an occasional patient is cured by palliative care. But this is never promised and almost never mentioned. If the patient is still with us five years later and their cancer appears to be gone, the patient is said to have experienced an outlier good response. If the patient is Roman Catholic and if the family prayed a novena or two, and if they have a favorite person on the short list for canonization, a miracle is declared--by all but the attending oncologists who do not believe in such things even though they witness outlier good outcomes from time to time.

The punch line: this kind of medical care has almost no support in Evidence Based Medicine. Not because it is not worth putting to the test--it definitely is for both humanitarian and economic reasons. But because it is nearly impossible to structure meaningful studies of the efficacy of these treatments for the fact that they impact quality of life not quantity of life and quality is entirely subjective.(If you consider human life sacred. If not, it is easy enough to make value judgements on the quality of the lives of others, but these judgements are what got the Nazis in trouble after they lost WWII.) And it is hard enough to structure prospective randomized clinical trials of curative interventions that have the power to discriminate between better and worse treatments when the clinical setting is objective and measures a single outcome: length of life. Obamacare is going to lean heavily on Evidence Based Medicine and so will certainly not allow paying for the kind of palliative care of cancer that is now in place in our country.

A million plus newly diagnosed cases of serious cancer are made each year in our country. Hundreds of thousands of these citizens will find at some time in the two or three years following their diagnosis that their cancer was not cured. And they will end up in need or want of palliative care. Obamacare for this will equal the red or the blue pill (or a federal admonition to be gracious enough to save the country the expense of any treatment and sign up for Hospice whose worthy philosophy is that when one has exhausted all effective interventions he or she should be ready to die with dignity and in as much comfort as the narcotics will afford.) Put a substantial death tax in place again and the federal purse will gain in another way. Do not forget the Social Security, Medicare and Medicaid, Veteran' Benefits, and other expenses not paid any longer. Oh, I forgot that palliative care as currently given for these problems does not prolong life. It just adds to or protects one's quality of life. Then again, very hard if not impossible to prove that contention within the conventions of Evidence Based Medicine. So there should be no problem eliminating these expenses. On to the next problem/expense . . .