Introduction

There are a number of treatments used to remove, reduce, halt the growth of a cancer or reduce the symptoms that may result from a cancer. The main treatments explored in the following chapters are identified in Figure 8.1.

Fig 8.1 Cancer treatment options

Making a decision regarding which treatment to offer an individual diagnosed with cancer is complex and has changed over the past few hundred years, and especially in the past few decades, as knowledge and skills have developed. There are many holistic considerations to make to ensure that the decision-making process reflects the wishes of patients, as well as giving them the best possible outcome in terms of life expectancy and quality of life. The decision to use a treatment is influenced by the cancer itself, the patient, treatments available and environmental and ethical factors, all of which will be discussed in turn.

Disease-related factors

Over time we have gained a better understanding of how cancer cells develop, how cancer cells behave, why surgery alone does not remove all cancer cells and why cancer recurs. Each type of cancer has been studied in detail and we now have an understanding of the likely progression and outcome of most cancers. For instance, some cancers spread to distant sites very early; others very late; others never spread.

The size and anatomical location of the cancer may dictate the treatment plan. It may be too big to remove surgically or the position of the cancer may make surgery difficult. For instance, if the cancer is too large or is too close to a major or sensitive organ/tissue, the surgeon may not be able to remove it completely.

The type of tissue is important as some tissues are more sensitive to chemotherapy or radiotherapy than others. Therefore, the histology taken from biopsies is crucial.

Ethical-related factors

All patients have the right to make their own decisions regarding treatment and healthcare professionals must respect this autonomy. It is the multidisciplinary team’s role to appraise all the relevant treatment options and the lead medical consultant’s responsibility to present the options and consequences of each option in a balanced and unbiased manner. The patient has the right to information in terms that they can understand, at appropriate times, and the opportunity to ask questions in order to make an informed decision and consent to treatment.

Although most patients wish to receive information regarding treatment options and many want to be involved in the decision-making process in varying degrees, some want to make the decision themselves while other patients would rather the consultant decides for them (the patient may think the consultant has more knowledge/experience). Some patients feel that the responsibility and pressure is too great; others feel overwhelmed by the trauma of a cancer diagnosis to make an objective choice; others want to be involved but view the decision as a joint decision between themselves and the healthcare team. No matter what their involvement in the ultimate decision, patients require tailor-made, accurate information so that they can make a balanced decision and give informed consent. Although the depth and amount may vary depending on the individual, healthcare professionals need to provide information regarding the type and extent of the cancer; what the possible treatment options are; what advantages might be encountered; and what the long-term effects of treatment might be. This information may need repeating several times and patients should be given an opportunity to ask questions. Encouraging patients and family members to write questions down helps them to remember what they want to ask about. Written information is particularly useful for referral at a later date.

All patients have the right to access cancer treatments fairly. However, in the UK, the availability of cancer treatments has not been equal for all patients. Prior to the Calman Hine report (DH 1995) and The NHS Cancer Plan (DH 2000), there was a great deal of regional variation regarding access to cancer treatments, quality of care and healthcare expertise. Each local health authority decided which cancer treatments would be available based on financial budget, immaterial of the effectiveness of drugs or the needs of patients. This resulted in spending variations, known as the ‘postcode lottery’, which may have contributed to higher death rates in some areas (although this was never proven). As a consequence of The NHS Cancer Plan (DH 2000), NICE was set up to review the clinical research trial evidence for each type of cancer and decide which treatments were effective and financially affordable. These two concepts are often in conflict and create ethical debate. Although there has been a reduction in regional inconsistencies and improved national access to research-based and cost-effective treatments, not all treatments are approved by NICE, and those that are approved are still sometimes unavailable and inaccessible by some patients.

Patient-related factors

The patients’ level of education and previous experience in the health service may affect the treatment options as they may be able to comprehend more complex information, may understand the healthcare system and may seek alternative opinions. As well as knowledge, patients’ financial circumstances may allow them access to treatment not available on the NHS.

Patients’ values and beliefs about cancer and treatment may also influence their decisions. These may be based on previous experiences and beliefs. For example, a patient who is a Jehovah’s Witness may refuse a haematological transplant, as this will involve the transfusion of blood products (Holland & Hogg 2001).

Although a patient’s age will not necessarily directly influence the treatment they receive, the older the patient is, the more likely it is that they may have other medical conditions (co-morbidity) such arthritis, diabetes, etc., which may affect the body’s ability to cope with cancer treatment. To measure a patient’s general wellbeing objectively, assessment tools are used such as the Karnofsky scoring system and the World Health Organisation (WHO)/Eastern Cooperative Oncology Group (ECOG) score (Table 8.1, p.82). This is used to determine whether a patient is fit enough to tolerate treatment.

Table 8.1 ECOG performance status (Oken et al 1982)

Grade	ECOG
0	Fully active, able to carry on all pre-disease performance without restriction
1	Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g. light house work, office work
2	Ambulatory and capable of all self-care but unable to carry out any work activities Up and about more than 50% of waking hours
3	Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4	Completely disabled Cannot carry on any self-care Totally confined to bed or chair
5	Dead