Palliative care in cervical cancer, part I | Lois Ramondetta, MD
As Cervical Cancer Awareness Month comes to a close, I find myself more tormented and frustrated about the status of health care in the United States when I see a woman who has been diagnosed with, treated for, or dying from cervical cancer than I do with any other gynecologic cancer. Delivering bad news is never easy, but telling someone that they have cancer is especially difficult when we know it could have been prevented.
I work in an environment where most patients are uninsured and without continuous access to health services, so I care for many women with advanced cervical cancer and many more women with recurrent or incurable cervical cancer.
In attempting to care for and treat women with incurable cervical cancer, the issue of futile care and palliative solutions seems so much more palpable to me. Pain, for instance, is much more common in women with recurrent cervical cancer than with other gynecologic cancers. Combining these severe pain symptoms with low health literacy and excessive social stressors, we are left with one of many tragic triads within the scope of life of women with cervical cancer.
Adding bevacizumab to standard treatment, regardless of the controversy, has given some hope to those experiencing recurrence and increased the previous improvement of 3 months Overall Survival (OS) to as much as 5 months. In my experience, there have been cases where adding bevacizumab initially appears to melt away the tumor and give a false sense of optimism to both the physician and patient. Eventually, gynecologic oncologists treating incurable cervical cancer need to determine what level of care or treatment should be offered after standard therapy has been given knowing that the response rates are slim to none.
Some people have posed the question why palliative care for cervical cancer patients is different from ovarian cancer. Cervical cancer settings are different for many reasons. We recently looked at symptoms at time of referral to palliative care and found more than half of patients with advanced cervical cancer were significantly burdened with pain, anorexia, a poor feeling of well-being, fatigue, insomnia, and constipation at the time of palliative care referral. The burden of disease for the majority of these patients always seems so much greater.
For many of these cervical cancer patients, the level of health literacy seems lower (e.g., they did not avail themselves of screening tests) or maybe the stressors that kept them from getting regular screening tests (denial, fatalism, fear or family burden) in many cases seem more severe. Research has shown that women with cervical cancer often come from a lower socioeconomic background and therefore may feel the pressure of out-of-pocket costs to a greater extent than other gynecologic patients.
Does any of this matter as we make decisions with and sometimes “for” patients about how they spend the rest of their lives? If a patient says, “Whatever you say, Doc,” do we take this information into account? Do we tell them that there is always one more chemotherapy agent, or do we tell them that we have no proof that their life will be extended or of better quality with additional treatment?
Or do we tell our patients about the Temel paper, which states in part, “Palliative care, with its focus on management of symptoms, psychosocial support, and assistance with decision making, has the potential to improve the quality of care and reduce the use of medical services.”
Do we always ask the patient and ourselves, “What is your goal for the rest of your life?
Lois M. Ramondetta, MD, is a Professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center, Houston, TX, and Chief, Division of Gynecologic Oncology, Lyndon B. Johnson General Hospital, Harris Health System, Houston, TX. Part II of her blog post on palliative care in cervical cancer will appear next month in SGO Issues.