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To Push or to Pull

For my week-long blog for Powell's.com, I'll be attempting something novel. Every day, I will pick a single recent case from my files that highlights a major new discovery in cancer science or cancer medicine. As always, the names and dates will be scrambled to protect the identities of patients. And I will provide a link to the major medical or scientific study that lies behind the case. My goal here is to demonstrate how every case in medicine is a story in its own right — and how grand ideas are inevitably concealed within the homunculus of each story.

÷ ÷ ÷

Robert Bernard was a 77-year old advertising executive diagnosed with advancing leukemia who came to the clinic seeking advice. Bernard came from a large, voluble French-Canadian family — and much of that family, as it turned out, was also in the room with him. His wife, two sons, and a daughter had flown into New York from various parts of the planet. They were a tight-knit group, talking each other in an internal language that needed few words. The father, children, and even their mother resembled each other so distinctly that it seemed each was another incarnation of the other, displaced by a few decades. The Bernards were a unit, and they knew it.

The family wanted to do everything possible — chemotherapy, bone marrow transplantation, experimental drugs — if possible, all three. Robert agreed, nodding enthusiastically. I told him that he had a slim chance of a sustained response, and a slimmer chance of cure. But they had already made their mind up. We drafted a plan, involving a visit to place a centralized catheter to infuse the chemotherapy. Robert would return in a week, and we'd start right away.

I finished my note and was about to move to my next patient, when the nurse knocked on the door. "Robert wants to ask a question," she said. She ushered him in — this time, alone.

The man who came through that door was quite unlike the man I had seen with his family.The man who came through that door was quite unlike the man I had seen with his family. Alone, without the pressure to satisfy his children, and without the desire to perform, Robert was a transformed patient. He knew his leukemia was incurable, he said. He knew the risks and benefits of trying the more aggressive form of chemo and transplantation. But it was only alone, without his family, that he could admit the inadmissible: he had no desire to try aggressive therapies. He wanted palliative care and supportive medicines — drugs to keep his blood counts high, drugs to relieve pain. In private, he was, in effect, retracting the plan that we had made. He was not depressed; his mind was clear, his goals lucid. I agreed.

In a sense, the push-pull quality of Bernard's story was emblematic. This drama, or a variant of it, is played out in the clinic every day. Some patients (or their families) push for therapies in the hopes for the slim chances of longer survival. Others pull back; they want palliative and supportive care. Even the words "push" and "pull" become loaded. Pushing implies a positive force, a desire to succeed, no matter the slimness of chance. Pulling implies an acceptance of the inevitable, a decision to embrace death.

But does "pushing" ahead with therapies always mean longer survival? Last summer, an enormous trial on lung cancer patients turned this idea on its head. The trial set out to answer an ambitious question. Metastatic lung cancer is typically a lethal disease: with conventional chemotherapy, only 5% of patients survive at 5 years. So palliative care, rather than chemotherapy, is a perfectly reasonable option. The assumption was that palliative care might increase the quality of a patient's life, but might come at the cost of survival. But when the trial was completed, there was a surprise: palliative care did not merely alter quality of life, it actually increased survival.

These results give us pause about how we think about "palliative care." As one of the leading researchers on the study put it: "One of the most common misconceptions about palliative care is that it indicates treatment has failed — that it means giving up. [But] in this study the addition of palliative care early in the course of illness extended the survival of patients with incurable lung cancer. These patients not only lived longer, but also experienced improved quality of life and were better able to enjoy the time they had remaining." In the case of metastatic lung cancer, at least, palliation was not just life-enhancing, but life-extending.

÷ ÷ ÷

Siddhartha Mukherjee, is a cancer physician and researcher. He is an assistant professor of medicine at Columbia University and a staff cancer physician at Columbia University Medical Center. A Rhodes scholar, he graduated from Stanford University, University of Oxford, and Harvard Medical School. He has published articles in Nature, the New England Journal of Medicine, the New York Times, and the New Republic. He lives in New York with his wife and daughters.

Books mentioned in this post

  1. The Emperor of All Maladies: A...
    Used Hardcover $9.95

Siddhartha Mukherjee is the author of The Emperor of All Maladies: A Biography of Cancer

3 Responses to "To Push or to Pull"

    Marlene Head November 16th, 2010 at 2:10 pm

    I look at palliative care as something that should be available for every serious illness, and pain management, to me, is the single most important part of it. We could do a much better job of pain management in this country if we took seriously how critical it is to a sick person's quality of life.

    TTuggle November 16th, 2010 at 9:53 pm

    For the last 2 years, I have been spectator to a family in turmoil because of ovarian cancer. This family is large and extended family members are just as close as the immediate. Their bond is incredible. However, the person with the cancer is living soley to pacify her family and those who love and care for her. She is in the end stages now, but has little input when it comes to her care. She succumbs everytime to one more treatment, one more surgery...whatever it takes to survive. All of this to avoid causing the family to have to endure her passing and the grief that will follow. Just last week we found 4 new positive lymph nodes in mediastinum and axilla. The family wants them removed.....It breaks my heart. She is suffering so.

    Margarita November 17th, 2010 at 7:19 am

    I agree. Pain is stressful, and chronic stress can lower immune function. The body wants to heal itself. I think Western medicine forgets about the rest of the patient when treating disease, and we'd all do better if they didn't.

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