Fall brings school buses, a freshening breeze and an avalanche of meetings. There are seasonal sales, myriad projects and the splendor of colored leaves. The season is also announced, again and again, by a particular peculiar and perilous decision, which, no matter how much I try, I do not fully understand. Frankly, I just don’t get it.
“Jane, it is time to start chemotherapy.”
“What are the side effects?”
“Well, this is powerful chemotherapy. It is necessary to cure your cancer. It will cause hair loss. It will cause a drop in your blood counts. It might cause severe diarrhea. There might be numbness of your hands and feet… that can be permanent. It can damage the muscle of your heart. You could be allergic. You may require blood transfusions or be hospitalized. When we finish the chemo, we will start radiation. Do you want to hear about the radiation?”
“No, that’s OK. I think I have heard enough. That is really scary, but thank you for telling me. How soon can we begin? I want to start right away.”
“We can start in a couple days. First, there are a few things to do. You need blood tests, a bone marrow biopsy, an MRI of your brain with intravenous contrast, a MUGA scan, a PET scan with radioactive dye and the placement of a Mediport.”
“That is a catheter surgically implanted under your skin, and the other end goes to the right side of your heart. It is best way to give chemo.”
“Oh, OK … can we get all that done this week? I want to begin.”
“Sure. No problem.”
“Oh, and one more thing.”
“It’s fall. You need a flu shot.”
“Absolutely not. I do not believe in flu shots. I never get them.”
Huh? What did she say? She won’t get a flu shot? I am flabbergasted. Why? Let us explore my bafflement.
My patients will allow complex, devastating, overwhelming, life-changing surgery, radiation, immunotherapy, genetic therapy and chemotherapy. They may get rashes, headaches, joint pain, swelling, fevers and risk heart failure, kidney failure, liver failure, and who knows what else failure. However, they will, consistently, recurrently, refuse the simplest protection of all, a flu shot.
This is not a rational response. What is the risk of a significant side effect of chemotherapy? High. Very high. This is difficult treatment to kill a difficult enemy, and almost all patients pay some price. Occasionally a heavy price.
What is the risk of a significant side effect of routine flu vaccine compared to the danger of actually getting influenza, especially in immunocompromised patients? Apparently, many of my patients think it is far too high.
The truth is the opposite. The risk of a severe complication from taking the flu shot is literally, one in a million. The risk of even a minor side effect, like a chill or slight fever, is small.
The reason that experts recommend the flu shot to essentially everyone, is that the flu is a deadly disease. Thousands of people die every year in the United States from the flu; the average deaths in the United States over the last decade were 32,743 per year. Many of those people had weakened constitutions because of other medical problems … like, say, cancer and cancer therapy.
Several patients in any large oncology practice are killed each year by influenza. Rare is the death or even the injury from receiving the flu shot. I have given out tens of thousands of flu shots over the years and never seen a serious problem. The biggest issue is that the vaccine is not perfect … it does not protect every patient. However, you cannot “catch the flu” from the vaccine, because it is sterile … there are no intact viruses in the injection.
Cautions do exist: It is important to warn your doctor if you have an allergy to eggs or other component of the flu shot. If you have had that very rare condition, Guillain-Barre (a paralysis from spinal cord inflammation), then talk with your doctor.
What perplexes me, is that these facts are common and obvious. Chemotherapy and cancer care is tough and has serious risks. Flu shots are easy and rarely cause problems … and they absolutely save lives. So, why do patients refuse the obvious and easy, but consent to the complex and hard?
Part is a desire to maintain control over one’s body. Refusing the flu shot seems to be a minor choice, not a life or death decision. On the other hand, cancer is a terrible, frightening threat and seems almost beyond our ability to understand, let alone refuse recommended therapy. Therefore, we accept aggressive, toxic, high-risk treatment. Anything, if you will, to fight the dread disease and stay alive.
We fail to appreciate the danger. “The flu” sounds like a couple of achy days curled up in bed with a fever. Maybe we miss work for a week: Not a big downside. Therefore, we think that even the very slight chance of a vaccine side effect is “not worth the risk.”
We miss, that the flu shot is extremely benign, but influenza for many, especially those already frail, is a deadly disease. We tend to neglect the whole idea of “herd immunity”: Even if the flu turns out to be just a few days on the couch for you, the person you in turn infect may be severely injured … or worse. As part of a society, a community, a “herd,” if you will, we have a moral and personal responsibility to others.
In the end, of course, it is my role to advise and guide. The patient is in control of their life and health. I support whatever path they choose. Still, some decisions baffle. From where I stand, some paths stray too close to a cliff.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.
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