Routine treatment not yet justified

摘要

Most patients with advanced or metastatic cancer will at some point be considered for chemotherapy or, occasionally, biological therapy—for example, inter-feron. These treatments are of limited specificity and commonly result in short term toxicity; they may also be expensive. If cure or increased survival is a realistic possibility these considerations are important but do not alter the treatment approach. However, most cancers are incurable once metastatic and often respond poorly to chemotherapy, which can result in side effects, inconvenience, and financial costs without improvements in symptoms or survival. In practice, partly because of the limited resources available in Britain, chemotherapy is often not discussed with, much less given to, many such patients. Increasingly, however, patients demand access to all available options, and the issue then is should treatment be considered, and if so with single or multiple drugs (with of course variable toxicity and cost) given intensively or non-intensively? Common examples of these diseases include metastatic non-small cell lung cancer, colorectal and upper gastrointestinal cancer, and renal cell cancer. The table shows some of the treatments used. Though no systematic reviews have been published, anecdotal experience suggests that management policies for these diseases vary widely between surgeons, radiotherapists, and oncologists and also within these groups. Approaches vary considerably between institutions and nations, and in the public and private sector. Desperate patients who seek second opinions may also expose these differences, as will enthusiastic forays into the media by patients or colleagues. The media often highlight new and untested therapies without the tempering effects of peer review or trials. How should we judge treatment efficacy, and is it possible to achieve a consensus with regard to standard therapy for these diseases?