TROLLEYS & ONCOLOGY
Every Ethics 101 student wrestles with the trolley problem.
In this exercise, you are placed by train tracks watching a runaway trolley race towards 5 people who are going to be crushed unless you intercede.
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Every Ethics 101 student wrestles with the trolley problem.
In this exercise, you are placed by train tracks watching a runaway trolley race towards 5 people who are going to be crushed unless you intercede.
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If you pull a lever, the trolley will divert on a different track, where it is bound to kill one person.
In this situation, is it better to be passive or active?
Should you pull the lever or not?
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In this situation, is it better to be passive or active?
Should you pull the lever or not?
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While not quite as dramatic a scenario, a similarly freighted decision between inaction and intervention plays out in oncology clinics multiple times every day as doctors weigh the risks & benefits of adjuvant chemotherapy.
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In this context, the medical oncologist is asking themselves if it is worthwhile to administer potentially toxic treatment when there is no obvious presence of cancer.
The quandary arises because, despite confident pronouncements like “we got it all!” ...
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The quandary arises because, despite confident pronouncements like “we got it all!” ...
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... after a patient undergoes an operation to remove cancer, remnant cells can linger below the threshold of clinical detection, beyond the keen eyesight of the surgeon and even the microscope of the pathologist.
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In theory, just a single cell "left behind" can, given enough time to replicate, blossom into another tumor at the same site or, even worse, spread through the bloodstream to sow the seeds of metastases.
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Thus the doctor's dilemma: In a patient with no current evidence of cancer, but at risk for recurrence, can prescription of chemotherapy in the here & now be justified? And if the lever is pulled, and a patient is harmed by toxicity from treatment, is the oncologist culpable?
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In truth, the quandary is different than the trolley problem because, without pulling the lever, there is still an outcome in which there is no harm, namely when adjuvant chemotherapy is omitted and the cancer never returns.
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That's why studies like this one (nejm.org/doi/full/10.10…) are so very important!
Right now at the world's largest cancer conference #ASCO22 oncologists are celebrating the chance to give LESS chemo in a more selective fashion, and without compromising patients' survival!
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Right now at the world's largest cancer conference #ASCO22 oncologists are celebrating the chance to give LESS chemo in a more selective fashion, and without compromising patients' survival!
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Among other things, it's a vital antidote to the toxic reputation that oncologists only ever want to treat MORE, driven by profit, therapeutic heavy-handedness, or both
Our reputation as a specialty is all too often conflated with the noxiousness of the drugs we prescribe👇
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Our reputation as a specialty is all too often conflated with the noxiousness of the drugs we prescribe👇
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Colon cancer is the most common diagnosis I encounter in my GI oncology practice and my patients with stage II disease might now be safely spared the risks of chemo through rigorous analysis of their bloodstream for any remnant cells post-op.
#crcsm
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#crcsm
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And if there's no evidence of this Minimal Residual Disease (MRD) upon the closest scouring of the patients' circulation for tumor DNA then I likely don't need to 'pull the lever' of chemo at all
This is progress that should be celebrated!
Sometimes less really is more :)
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This is progress that should be celebrated!
Sometimes less really is more :)
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