To Undergo Chemotherapy Or Not

Headline: “How I used math to conquer my cancer” by Michael Kaplan.

Gist: fellow named Reitzen, 45, discovered he had kidney cancer.

“The doctor came up to my house and had fantastic bedside manner,” says Reitzen, now 57. “He told me that the tumor was larger than the kidney itself, which would necessitate removing my kidney and the lymph nodes around it.”

But Reitzen didn’t want a body part removed — unless data showed it to be absolutely necessary — so he sought a second opinion.

So Reitzen used “data mining”, i.e. he conducted a search of the Internet, to find the kind of surgeon he wanted. He found two. One “thought that it would be better for me not to lose [the kidney] because I had high blood pressure…He had no bedside manner, but I liked his opinion of there being a 70 percent chance that I would not be left with just one kidney.”

The cancer was duly hacked out. “But the oncologist/hematologist who gave him the original diagnosis suggested chemotherapy to avoid a recurrence.”

Using decision-theory math, Reitzen took into account the likelihood of surviving with and without chemo. With the chemo, there was an average life expectancy of 8.1 years; without it, he would be looking at 7 years.

But taking chemo’s side effects into account, his quality of life would be only 70 percent, which he based on information from health-related quality-of-life studies on chemotherapy patients. Without the chemo, he would have no side effects and 100 percent quality of life. After doing the math, quality-adjusted life years came to 5.7 with chemo and 7 without.

“Would you want to exchange a 15 percent life-expectancy increase for a 30 percent drop in quality of life?” he asks.

Quality-adjusted life years? Yet another attempt to quantify the unquantifiable. Wikiwik’s dry statement puts it best: “To be dead is associated with 0 QALYs, and in some circumstances it is possible to accrue negative QALYs to reflect health states deemed ‘worse than dead’.”

Reitzen’s calculation is simple: 8.1 years of “expected” life left under chemo times 70% (0.70) of “worthy living” equals 5.7 QALY. And 7 years “expected” life without chemo times 100% (1) of full life equals 7 QALY. Since 7 is greater than 5.7, the calculation says to pick no chemo.

Which was his choice: no chemo. “Ten years later, Reitzen is cancer-free, with two functioning kidneys, and did not have to endure the misery of chemotherapy. The treatment that he was initially offered has been deemed ineffective for kidney cancer.”

To which we say, God bless him. But do note, and do pause, at the statement The treatment that he was initially offered has been deemed ineffective for kidney cancer. And then recall that the “expected” 8 years he was to live with that now-deemed-ineffective treatment was calculated on the belief (or assumption) that the treatment was effective. All probability is conditional.

While Reitzen routinely makes critical investment decisions with the guidance of math, and found comfort in his cancer-by-the-numbers strategy, doctors don’t think his approach to treatment should be relegated only to statistics-loving professionals.

To which we say capital-A-men. A doctor’s “loss” and “gain” are different, and sometimes far different, than a patient’s. The internal “calculations” the doctor uses to recommend a specific treatment might be best in his mind and for him, but not for the patient. Only the patient can decide what a “worthy” life is.

Now the real problem is only partially the attempt to quantify the unquantifiable. A life’s worth cannot be put to a number, and doing so can only be the crudest of approximations. Collapsing a life’s worth to a single number necessarily strips away vast amounts of information. And that means bad decisions can be made.

The second difficulty is, even is all can be quantified, all should be quantified in its fullness. When it was believed (by at least that one doc) that chemo would work, this doc’s calculation said patients would live an “expected” 8 years. That number is found by multiplying the probability (conditional, as all these probabilities are, on the doc’s belief in the treatment) a patient would live one year by 1, the probability the patient would live 2 years times 2, and so on, the result being a weighted average.

Collapsing these probabilities to one “expected” number again strips away information. The whole swath should be presented to the patient—not necessarily at the finest levels. Do we really need information per year 10, 20 years out?

Well, you get the idea. What is most crucial to grasp is not all this numeric mumbo jumbo, but that not accepting harsh treatment is an solid option. Though it cannot be quantified, a shorter life without the brutal suffering caused by a treatment can be much better than one with it. Especially when it is, as it always should be, recalled that All men are mortal, etc.

31 Comments

  1. I think this is a truism: the older you are the easier it is to proceed w/o treatment. For me, at 82, to forgo an operation or chemo is much easier than at 50 when I had a wife and children to support.

  2. Yeah, I’m getting chemo now, and it is very rough. But I’m just under 50, and was otherwise in very good shape, strong and fit, what this hit me. Chemo was really the only option for me, and so far I’ve had “complete metabolic response,” meaning it’s working splendidly and my life expectancy should be nice and long. But there are many different kinds of cancer with many various effects. You have to be your own best advocate, study it very carefully, get as many opinions as you can, and make your own decisions based on sound logic and what you want out of life. If I was 80? Unless I was again in very good shape, I don’t know if I’d bother with the chemo, and rather just enjoy what days I have left with my wife and family and friends.

    JMJ

  3. But this is an example of where it’s his numbers and his statistics and his decision. He picked the numbers and he decided to rely on his calculations. The problem comes when people pick numbers out of thin air: “But taking chemo’s side effects into account, his quality of life would be only 70 percent, which he based on information from health-related quality-of-life studies on chemotherapy patients. Without the chemo, he would have no side effects and 100 percent quality of life. After doing the math, quality-adjusted life years came to 5.7 with chemo and 7 without.” and then using those number to dictate to someone else what they should or shouldn’t do. Or even suggest to someone what they should do. Some folks might choose the extra year. Who knows. But it would be their numbers and their decision.

  4. Briggs —

    This is the tangent where it gets tough …

    How does not agreeing to the acceptable treatment differ from euthanasia?

    What I mean is, if someone chooses to not select a treatment that will likely cure them, but accepts death as the other option, it that morally wrong?

    So, assume I have a disease that will most assuredly lead to my death in five years. I am suffering badly and want to end it all. Since euthanasia is illegal, it is not an option.

    One day, I am hit by a car when crossing the street. While bleeding, I demand no treatment knowing that will end my life and my suffering.

    Is that acceptable?

    Note: My position is death is personal. And people choose death, or their families may agree on their death. For me, the issue arises when government is involved, directly (via laws and regulations) or indirectly (via encouraging, through some means, for healthcare providers to end life in opposition to the wishes of the individual or family — though this excludes government not funding certain procedures).

  5. Briggs,

    For sure sure the doctor or hospital working in a capitalistic model have no incentive to suggest unnecessary treatment that will bring them 100s of thousands of dollars. Even more when the patient has a good insurance.

    In the US an hospital might not be for lucrative purposes that doesn’t mean that the administrators are no making the dough.

  6. Sylvain —

    As if the administrators in your utopian socialist hospitals would not make dough?

  7. Jim,

    Our hospitals have less administrations, so less administrator and a much lower cost spent in administration. A hospital CEO makes less $100 k a year compared to $400 k in the US.

    Do you really consider $100 a year a lot of dough. It is well paid but it’s not outrageous either.

  8. My daughter is a doctor at a the non-profit Children’s Hospital in a major city. The CEO makes $6 million per year. Something is wrong with this. But he is probably a good fund raiser.

  9. Sylvain —

    Either you are more rhetoric than research … or you make-up (lie) to defend socialism.

    “Ontario hospitals publish salaries of top executives, unveil ‘exorbitant’ packages”

    http://news.nationalpost.com/posted-toronto/ontario-hospitals-publish-salaries-of-top-executives-unveil-exorbitant-packages

    From the article:

    Ontario hospitals released the employment contracts of their top executives Tuesday, revealing a host of lucrative perks from million-dollar pensions, to personal trainers, to plastic surgery.

    https://plancanada.ca/document.doc?id=461

  10. All this talk about what a CEO gets paid grinds my gears. What someone is paid is exactly what the two parties agree with; and who are we to say that if we paid a CEO less that others would be getting more service? More likely, in my opinion, is that they get less service, overall and in the end. It does no one any good to be jealous, envious and covetous of what someone else earns. That’s not my concern.

  11. Oh, one other thing. This story has the person saying he’d have no side effects from not taking chemo. I did not see any indication that he considered any other factors, besides chemo (for or against) in this situation. He was blessed. Would we have heard this story if the opposite had been the result?

  12. cdquarles: What CEO’s make should be everyone’s concern. They are part of the 1% that has all the wealth. They take advance of the privileges of their position and basically orchestrate their own pay through stock buybacks and other forms of privileged and often corrupt dealing. The answer to this is much more competition which mega-corporations tend to thwart with the help of compliant (paid off) politicians.

  13. Jim,

    Yes, I remember this case. The problem with that one is that he works for the university not the government like the majority of the hospital CEO.

    In University the salary are attributed much like corporation. The deans recently became the center of attention and are now more careful if they don’t want their salary attributed by law, which would be less generous.

    We are still far from the $6 millions Mike talked about earlier.

  14. Cdquarles,

    Isn’t it your concern that your care cost 3 times as much as the next developed countries.

    Maybe health insurance premiums would not be so expensive if CEO took home a more reasonable pay check.

  15. No Sylvain, you outright lied. The ends do not justify the means, except for you socialists.

    You wrote, “A hospital CEO makes less $100 k a year compared to $400 k in the US.”

    This is blatantly not true. It is a lie. And you know it is.

    Then you misquote the article, claiming it references only one CEO.

    From the article:

    The salaries of some Montreal health-care managers:

    Sonia Bélanger, executive director of the CIUSSS Centre-Est-de-l’Île-de-Montréal: $257,950, up from $214,959, an increase of about 20 per cent.

    Yvan Gendron, executive director of the CIUSSS Est-de-l’Île-de-Montréal: $257,822, up from $214,852, an increase of about 20 per cent.

    Pierre Gfeller, executive director of the CIUSSS Nord-de-l’Île-de-Montréal: $274,074, up from $239,427, an increase of 14.5 per cent.

    Benoît Morin, executive director of the West Island CIUSSS: $226,789, up from $188,991, an increase of about 20 per cent.

    Fabrice Brunet, executive director of Sainte-Justine Hospital: $253,772, up from $247,127, an increase of 2.6 per cent.

    Denis Roy, executive director of the Montreal Heart Institute: $234,974, up from $224,859, an increase of 4.5 per cent.

    Renée Fugère, executive director of the Institut Philippe-Pinel: $196,301, up from $178,456, an increase of 10 per cent.

    I will no longer debate you through your smokescreen of lies.

  16. Jim,

    1-My figures of $100k comes from data a list of salary for governmental jobs.

    2-The article refers to the CEO of of CUSM(French acronym) which is part of McGill University and paid by the university through scolarity fee of McGill students and what the government gives them per student and finally research financed by the industry.

    3-All acronyms that end with triple “S” are not hospital CEO. They are regional entities that we could very well do without. These entities are responsible mainly of coordinating between hospitals.

    4-Sainte-Justine and heart institute are part CHUM (Montréal university)

    Your idiotic claim that I lied because of salary that were not completely the same doesn’t hold since in the USA the CEO salary is at least double that in Québec.

    If you were to compare apple with apple, Philadelphia is about the same size has Montréal:

    http://www.philly.com/philly/business/175896851.html

    Catholic health east provide $14 millions salary for only 5 people (Christian charity at its best).

  17. Sylvain —

    No. You stated $100K as the salary that no CEO of a Canadian hospital made. A claim you knew was false — as in a lie. You wrote, “A hospital CEO makes less $100 k a year compared to $400 k in the US.”

    Give it a break. The articles prove you lied to make a point, regardless of your defensive equivocations. You have no — as in none — credibility.

  18. Jim,

    No wonder the USA is the laughing stock of the world. You elected the biggest idiot around and not even smart enough to realise it.

    The USA are now the weakest they have ever been and getting weaker by the day. Living all the ground to Russia and China who own Donald J Trump.

    How long will it take before he is sent to jail?

  19. Jim,

    How long do you think it takes the normal person to realize that you stick with the $100 K while ignoring that my figure of $400 K was much lower than reality.

    This is a good attempt to divert from the fact that you compared the salary of Canadian CEO to US CEO when you stated.

    ”As if the administrators in your utopian socialist hospitals would not make dough?”

    In Canada, salary over $100 K pay 51% of taxes.

  20. Sylvain —

    Is it tough continuing a lie in the face of evidence to the contrary.

    I trust readers will open the links I provided and see this:

    “At $1,500 a month, Sunnybrook Hospital president and CEO Barry McLellan received one of most generous car allowances, which were common among the CEO perks. Mr. McLellan, who earned about $688,000 in 2010, also receives $20,000 to spend on private clubs, legal counselling or as a mortgage subsidy.”

    This is your tactic: lie to defend dream of socialism.

    I am moving on. You can live your lie.

    Sad.

  21. Yet avoiding again that in the USA you have guys that make twice to 10 times has much.

    The fact remains that CEO in the USA make a lot more dough than Canadian.

  22. Sylvain —

    I have no intent on trying to keep up with your lies, equivocations, non sequitars, etc. You have no credibility left.

    Maybe you can peddle them elsewhere.

    Sad.

  23. Jim,

    While you complain about lies. People to whom I show your comment too have a lot fun reading your comment. They can’t understand how stupid Americans really became.

    I used to have respect for American but this blog destroyed all that. You can be really happy that I am now really great at showing how American really are. After talking with me for 5 minutes no one wants to move there.

    The only thing Canadian envy the US for is the southern climate.

  24. After talking with me for 5 minutes no one wants to move there.

    That’s a relief! Clouds do have silver linings after all.

    Anyone with the smarts to stop listening to you after about a minute is more than welcome. C’mon down!

  25. DAV,

    The problem is that they find American like you idiotic, so they will not be coming down.

  26. Gosh! We can always count on you for such profound and cogent replies. I’m kinda busy just now, though. Can I ignore you later?

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