By Dan Labriola ND
Now that you’ve chosen your cancer doctor(s) you need to decide on treatment. Options come with differing effectiveness, side effects, duration of treatment and, frequently, a recommendation. You can simply accept the first recommendation from your doctor, which may well be the best, but, since you are unique and know yourself best, I suggest you participate in the decision process. There can be points about one treatment versus another that are more important to you than the doctor realizes. At this point you are probably ready to just move on but you don’t want to look back later with regret for a decision made in haste.
The treatment decision process comes down to evaluating the benefits versus risks for each option. Your cancer doctor can walk you through the details keeping in mind that you will not experience every possible side effect. The most effective treatment with the least side effects wins although there may be some tradeoffs. For example, with breast cancer, under some circumstances a woman can choose between lumpectomy, removal of just the tumor and some surrounding tissue with radiation or mastectomy without radiation. Both procedures have very similar effectiveness.
Fortunately there is a lot of credible evidence for evaluating benefits based on well done research. In most cases you will be presented with relapse and overall survival statistics for a time period after treatment such as 5 or 10 years depending on the particulars of your diagnosis. These numbers help you choose the treatment that is statistically best but keep in mind that these are still just statistics and you are not a statistic. Don’t let the numbers bring you down.
In addition to FDA approved therapies there are clinical trials that are worth considering. Enrolling in a clinical trial not only moves us closer to finding an answer to cancer but may also offer an opportunity to benefit from a new therapy. Some clinical trials also present risks so it’s important to weigh the benefits and risks for you before signing up. Cancer clinical trials are separated into 5 phases.
Phase 0 trials represent the first step in using a new treatment on humans. Small numbers of patients are given minimal doses of the treatment to see how it acts chemically in the body. These trials do not usually collect information about effectiveness or side effects and are generally only for patients for whom there is no known, effective treatment.
Phase 1 trials determine the safety of a new, experimental treatment by evaluating the maximum tolerated dose. Side effects are evaluated carefully but effectiveness data may or may not be evaluated.
Phase 2 trials are the first step to evaluate how effective a new treatment is once safety considerations are understood.
Phase 3 trials also evaluate treatment effectiveness but in much greater detail with larger cohorts of patients than phase 2. These investigations are frequently randomized where some patients receive placebo. They also frequently evaluate how the new treatment compares to existing treatments.
Phase 4 trials are usually conducted after the new treatment has received FDA approval to collect more data. They are called Post Marketing Surveillance Trials and may be funded by pharmaceutical companies.
If you are invited to participate in a clinical trial you will be given information including an FDA approved Informed Consent Form. Every trial is different and your oncologist will help you understand the benefits and risks. You can find a list of all the current FDA approved clinical trials in the U.S at www.clinicaltrials.gov.
Once you have chosen a treatment you have the option of getting a second opinion, a valuable service that is underutilized because patients feel that seeking one would offend their doctor. The fact is that no one will be offended. Second opinions are a normal part of cancer care and they provide you with an opportunity to have another pair of eyes look at your diagnosis and treatment to see if there is something better or different that should be considered. The process is simple, can happen quickly and is usually covered by insurance.
You start the second opinion process by getting referrals as you did when looking for your cancer care team. There may be a doctor you already know about. It is best to choose a provider from an unaffiliated institution. Different cancer programs sometimes have different, possibly interesting protocols for the same diagnosis and it also minimizes the possibility for a rubber stamp if the reviewing doctor works too close to your doctor. The reviewing doctor’s office will help you get a copy of your records sent.
The second opinion can have 3 possible results. First and easiest is agreement with the planned treatment. If you’re satisfied you can move forward with the plan. The second, not uncommon, response is a recommended plan that is different but equivalent effectiveness. Unless the differences are significant you will likely go forward with the original plan.
If, however, the reviewing doctor recommends much more, much less or something very different you now need resolution. This doesn’t happen often and is most frequently settled by the 2 doctors speaking with each other. If that doesn’t work or isn’t possible then you need a tie breaker, a rare occurrence but when it happens you need to get to the bottom of it before starting treatment. You can find your 3rd opinion using the same strategy you used finding the second opinion. You may want to consider a larger cancer center even if it means traveling. If travel is not an option, some record reviews can be done without the patient present.
One final note on choosing therapies. The FDA does not allow claims to be made about a treatment without first substantiating them with human trials. Unfortunately, there are individuals and clinics in the US and elsewhere claiming cancer cures without the human evidence to back them up. Be aware that while test tube and animal studies are useful in science they only rarely translate into treatments that work on people. We were curing cancer in laboratory animals using just vitamin E 50 years ago but when the same protocol was tried in humans it didn’t work.