CANCER TREATMENT DECISION-MAKING
Having carried out a biopsy and appropriate imaging, a decision has to be made about the treatment approach for the patient. An important initial decision is whether or not cure is feasible. If treatment is going to be essentially palliative, this must be factored into decision-making – the quality of life becomes paramount. If treatment is potentially curative, then different considerations apply – research has shown that patients will endure considerable side effects in return for a chance of cure. Whether the aim is the cure, life prolongation, or palliation of symptoms, a range of approaches are available and may be used either alone or in combination. Decisions need to be reviewed on a regular basis and treatment adapted in accordance with side effects and tumour response – that is, whether or not things are improving.
Increasingly, in major healthcare systems, these decisions are not made by individual doctors but by a multi-disciplinary team, usually abbreviated to MDT (in the UK, this is now mandatory if the hospital is to receive reimbursement for cancer therapy). Typically, these teams will comprise surgeons, radiation and medical oncologists, radiologists, pathologists, and specialist nurses. The MDT will review the baseline information (termed staging information) prior to the consultation with the patient to review the various test results. Generally, these decisions will be based on national or international guidelines on best practice. The results and treatment options will then be discussed with the patient in the clinic, and the clinical plan finalized.
The various treatment modalities will be dealt with in turn, but before doing so, it may be helpful to give a broad breakdown of the relative importance of the treatment modalities. Figure 1 gives an estimate of how 100 ‘typical’ patients would be treated in a modern Western health care system.
Clearly, the numbers are for illustration only and will vary by country, and even within countries with local practice. For example, bladder cancer can be managed either by surgery to remove the bladder (cystectomy) or by radiotherapy to destroy the tumour, with surgery reserved for salvage of radiotherapy failures. In the USA, very few patients are managed electively with radiotherapy, which is reserved mostly for palliation (symptom control) in the elderly and frail. In contrast, in the UK, around two-thirds of patients are managed with primary radiotherapy, with surgery focused on the younger, fitter patients. These differences in practice stem largely from the differences in the UK and US health economies rather than any evidence-driven differences.