Relationships trump treatment when it comes to beating the odds in advanced cancer, at least according to one small group of patients who have far outlived their prognoses.
Fifteen patients with advanced lung or pancreatic cancer attributed their longevity to their relationships with their doctor and their family, rather than the type of treatment they received.
An article outlining their cases was published online in Future Oncology. Although most of the patients in this small cohort used some form of complementary and alternative medicine, they did not consider it to be a main cause of their survival. Rather, the main recurrent themes in most of the interviews were patient–doctor communication, family support, and the patient's proactive attitude in accounting for their remarkable survival.
"This study emphasizes two main factors in survival," said lead author Moshe Frenkel, MD, clinical associate professor at University of Texas Medical Branch, Galveston, and director of the integrative oncology service, Meir Medical Center, Kfar Saba, Israel. "First, being active and involved in the care of each patient is extremely important, and second, having a unique physician that can think out of the box can be a major factor in survival of cancer patients."
A crucial observation is that although most of the patients in this group used complementary therapies as additional options of care, they not did perceive this to be a major contributor to their survival. "This was an important point, as most people look for a magic wand that would clear the cancer and get them back to normal life, but this was not the case," Dr Frenkel told Medscape Medical News.
Cases in which patients have an exceptional disease course and experience spontaneous regression of cancer have been well-documented, but the research that has examined these stories has been limited and largely incapable of providing a satisfactorily clear explanation. "Most articles are based on anecdotes and not on systematic research, and it is very hard to make conclusions when information is coming only from anecdotes and case reports," said Dr. Frenkel.
Different Mechanisms and Common Themes
Some studies have focused on a wide array of possible physiologic factors and psychological mechanisms. Other research has observed that some patients have undergone some kind of spiritual awakening before their disease remission occurred, suggesting that the patients themselves had an important role in the healing process. In her book Radical Remission: Surviving Cancer Against All Odds, Kelly Turner, PhD, analyzed more than 1000 cases of spontaneous remission and identified more than 75 different healing factors that patients used to help heal themselves. As previously reported by Medscape Medical News, nine factors stood out and were used by almost all of the survivors. These key healing factors involved body, mind, and spirit interventions.
"Everyone has seen cases like this in their practice," Dr Turner told Medscape Medical News at the time. "Yet few have ever investigated them."
One such investigation, undertaken as a collaborative effort between the University of Texas MD Anderson Cancer Center, in Houston, and Israeli researchers, identified 26 "exceptional" patients. Interviews with this cohort revealed several common themes: activism, open communication with physicians, support from family and friends, and belief in a higher power (Support Care Cancer. 2011 Aug;19(8):1125-32).
However, one of the weaknesses of that study was that the true occurrence of these patients among the general population was not reflected in the small sample size, and another limitation was the selection bias, because the patients were identified by their treating physicians, according to the authors.
Hardship and Gratitude
In the current study, which was conducted in Israel, Dr Frenkel and colleagues identified exceptional patients through a computerized population registry system that is part of the Israeli healthcare system. This allowed them to ascertain the true occurrence of these patients with specific cancer types that are associated with a very poor prognosis. This registry accurately tracks patients' medical care, and patients cannot disappear from the system.
There was also no mistaking the diagnosis, nor were the problems involving incomplete information on the patients. "We had access to the full medical records with all conventional workup and verification of diagnosis utilizing objectives measures, all after complying with the institutional review board and local regulations," he explained.
A total of 23 patients with advanced lung or pancreatic cancer were identified through the regional computerized registry. These patients were given an expected 5-year survival rate of less than 15%. Of this group, 15 participants agreed to be interviewed (nine women and six men).
Eight of the patients had advanced lung cancer; seven had pancreatic adenocarcinoma. The mean duration of their survival since diagnosis was 8.2 years (range: 5 - 15 years). The average age was 70 years, and all patients had received conventional treatment, including surgery, chemotherapy, and radiation therapy.
The authors note that many of the patients could not see themselves as either past the disease or cured. "For many of these patients, who still suffer from symptoms of cancer and from deterioration in their functioning, the definition of survivorship can only be understood literally: that is, not having perished, but certainly not in terms of having won the battle with the disease," they write.
But because many of them were elderly, it was somewhat difficult to disentangle the effects of cancer and of aging on their functioning. Some of the patients found their longevity to be a burden, because they were still alive but not healthy. "Some of these patients survived the disease, but with a cost," said Dr Frenkel. "But still...all were very grateful that they were still alive."
Three Underlying Components
The most prominent theme was the patient–doctor relationship. The authors point out that the typical account emphasized the roles of the "bad" (or vilified) physician and the "good" (or idealized) physician. The "bad" physicians, according to the patients, were those who lacked the proper vision to make an accurate diagnosis or who were rude, dismissive, arrogant, or disrespectful.
Conversely, the "good" physician were portrayed as something of a savior. They were described as being omniscient, omnipotent, benevolent, engaged, sensitive, and decisive.
Family support was also one of the strongest themes among patients and was acknowledged by all but two participants. Family members boosted morale, helped financially, helped with logistics, such as driving the patient to the doctor or hospital, provided medical advice in cases in which the family member was a healthcare professional, and used personal connections to further care (knowing someone in a key or important position).
The third component was having a proactive attitude, and that manifested in many ways, according to the patient interviews. Some patients got second opinions, they asked for advice from lay people, such as friends, neighbors, and family, and they turned to the private healthcare sector (after being dissatisfied with the public services). Some went abroad for treatment, changed physicians, pressured their doctors to get more tests and further the diagnosis and, at times, openly questioned the diagnosis.
A seeming drawback to the study is the small population in Israel and thus a small patient sample. But Dr Frenkel pointed out that conducting the study in a country with a small population is actually an advantage. "It is very hard to track patients in a big country," he said. "This is where the big advantage and not the drawback of having a small country, where identification and follow-up is more accessible and easier to follow. So far, this format of study was done only in Israel."
He and his coauthors note that further research is needed to determine the true frequency of these outliers, the types of cancer these patients have, and the characteristics they might share.
The study was funded by the Reliable Cancer Therapies Fund (Verbier, Switzerland) and by Clalit Health Services (Israel). The authors report no relevant financial relationships.
Future Oncol. 2015;11:1741-1749. Abstract
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Cite this: Longevity in Advanced Cancer Attributed to Relationships - Medscape - Jul 08, 2015.