Quality of life issues in caring for cancer patients

Not many years ago it was assumed that most cancers were not caused by viruses. Today it is clear that many are and the list is growing. Head and neck cancers are either caused by the environment (especially tobacco) or by the human papilloma virus, the same virus that causes cervical cancer and some genital warts.

The incidence of HPV-related head and neck cancer has been rising rapidly in the past few decades, especially in white men, perhaps due to increased oral sex. Indeed from uncommon in the past, HPV-associated oropharyngeal cancer now represents about 70% of all new cases. The lag time from exposure to disease is from 15 to 30 years with most cases detected among men in their fifties. It is not yet clear why men are affected to a much higher degree than women nor why it affects whites more than blacks.

This increase however is further reason why the HPV vaccine initially licensed for cervical cancer should be given to both girls and boys, as recommended by the Centers For Disease Control (CDC) immunization advisory committee recently. Most HPV-associated oral cancers are due to HPV-16, one of the serotypes in the two available vaccines. Interestingly, those with HPV-induced throat cancer respond to therapy better than HPV-negative patients.

I am pleased that quality of life issues are being more and more addressed in caring for cancer patients. Supportive care in general was a major interest of mine throughput my clinical and research career and along with Jean Klastersky and Han Georg Senn we founded The Multinational Association for Supportive Care in Cancer (MASCC) which has become an international leader in these fields.

One recent study of lung cancer patients showed that having a palliative care team work with the patient with lung cancer from the time of therapy initiation leads to multiple beneficial outcomes (less pain, less depression, and better quality of life overall.) As a group they were less likely to request aggressive therapy at the end of life yet had an increased survival. This is somewhat reminiscent of the Stanford study by Dr Spiegel years ago demonstrating increased survival (along with lessened pain and decreased anxiety) among patients with metastatic breast cancer with the use of support groups.

Palliative care is a modality many think of as only relevant at the end of life but in actuality the team (often a physician, pain specialist, nurse, chaplain and social worker plus others as needed) can offer much support early on which can be exceedingly useful. They have expertise in pain management plus can teach the patient how to best interact with his or her physician(s) to obtain what they need. This latter is very important. Most patients are hesitant and need to understand/learn how to be assertive without being annoying. And support groups give each member the opportunity to realize that others are experiencing many of the same problems – and some have found good techniques to address them.

Complementary or integrative medicine can be of great assistance to patients with cancer.  The use of yoga to assist with sleep and fatigue has been proven useful. So too has acupuncture for some pain problems and the nausea of chemotherapy; meditation for stress reduction and stretching and mild exercise for a general sense of well being. Many of the mind-body techniques including visualization, meditation, the relaxation response, and Tai Chi can be beneficial. So too can good music and Reiki assists many. The opportunities are legion and the benefits are real; an open mind is essential but review of the proven results at reputable web sites like the NIH is important.

To conclude this series on advances in cancer care: There are increasing numbers of drugs designed specifically as targeted therapies such as the new drugs recently approved for metastatic melanoma. Their cost, unfortunately, is very high and must be considered in light of the often limited added benefits yet still substantial toxicities. There are new and often controversial approaches to screening for cancer. The recent recommendation to stop doing most PSA tests in men has led to many forceful expressions of disagreement. So too with the recommendation two years ago to change the standards for mammography. And now it will be important to determine if low dose CT screening for lung cancer in high risk individuals is appropriate given the costs, the tumors found yet the high number of false positives.

The HPV vaccine has now been recommended as important for both boys and girls – to prevent cervical cancer but also to prevent oral cancers, the latter rapidly increasing in incidence. Finally, there is good data to recommend the use of palliative care early in the treatment of cancer and to use various complementary medical approaches for patient comfort, lessened anxiety and depression and pain relief.

Stephen C. Schimpff is an internist, professor of medicine and public policy, and former CEO of the University of Maryland Medical Center.  He is the author of The Future of Medicine — Megatrends in Healthcare and blogs atMedical Megatrends and the Future of Medicine.

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