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|Year : 2019 | Volume
| Issue : 4 | Page : 381-383
News from the world of oncology
|Date of Web Publication||11-Oct-2019|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. News from the world of oncology. Indian J Cancer 2019;56:381-3
| » Singles Are Less Likely to Receive Cancer Treatment Than Married Individuals Due to Implicit Bias of Physicians and Society|| |
A recent study published on 5th September in the N Engl J Med. 2019;381(10):982-985, titled “Death by stereotype? Cancer Treatment in Unmarried Patients” by Joan DelFattore [Figure 1], Ph.D. has brought to fore the discussion about bias encountered by singles in receiving cancer treatment.
The study was conceived by Dr. DelFattore after encountering such a bias herself when she was diagnosed with gall bladder cancer infiltrating the liver in 2011. She underwent surgery and clear margins were obtained post resection. She was then referred to the medical oncologist for chemotherapy. The most promising treatment available was that of a combination chemotherapy of gemcitabine and oxaliplatin, but on getting to know that the author did not have any immediate family and that she would be relying on her friends and colleagues for the treatment, the medical oncologist suggested that she be treated only by gemcitabine as she was single. Dissatisfied by the offered treatment option (induced by physician's bias), the author moved on to another medical oncologist who gave her chemotherapy with gemcitabine and oxaliplatin. This personal incident prompted her to investigate whether the bias was merely a co-incidence in her case or whether physicians had similar views in general, when it came to individuals not having the traditional support system of marriage.
84 studies indexed on MEDLINE which drew statistics from Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute were the basis of the study.
The important findings of the study were:
- 45% of Americans are unmarried and the number of single individuals is increasing
- Cancer survival rates are lesser in single individuals
- Single individuals are slightly more likely to refuse surgery (0.52%) vs 0.24% in married individuals and radiotherapy (1.33%) vs 0.69% in married individuals. It is assumed (without any concrete evidence) that this discrepancy is due to “lesser fighting spirit” and “lack of committed partner for whom to live for”. However, since the refusal rates are less than 1% and 2% respectively in surgery and radiotherapy groups, it does not imply that they are more likely to refuse treatment than their married counterparts
- Physician's attitudes towards race, ethnicity, gender and sexual orientation have been well documented to determine their treatment decisions. It is well documented that physicians just like other human beings have a tendency to form stereotypes about unmarried adults relying more on the existing cultural views and personal experiences rather than on existing data. This implicit bias of physicians against unmarried adults may thus influence research and their clinical attitudes towards them
- The author has shown in her studies that there are strong generalizations made about single people, without any scientific data backing the same. She quotes an example where a cross- national study [Reference: Weissman MM, Bland RC, Canino GJ et al. Cross-sectional epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293-9] on depression shows that 4.3% of married individuals are depressed, while 11% of divorced/separated individuals are depressed. This study does not take into account singles who never married and yet comes up with a suggestion that unmarried people should be screened for depression thus indicating the bias.
In an email conversation with the author, this correspondent asked some questions to which her replies were as follows:
NC: What are the reasons behind the biases faced by single people in receiving cancer treatment?
Joan: For centuries, adults – especially women living without a spouse – have been viewed as inferior and sometimes even as wicked. Certainly, they have traditionally been seen as lacking the support that could allegedly come only from marriage. Although that social belief remains strong today, the reality is that many people are marrying later or not at all, divorcing more readily, and remaining single after divorce or widowhood. In the U.S., 45% of adults are unmarried. This highly varied population includes many who have strong networks of friends, extended family, neighbours, and colleagues. But social attitudes have not kept up with these changes, and physicians cannot avoid being influenced by the culture around them. The results are evident in the dozens of medical articles I examined. Contrary to what extensive psychological and sociological research actually shows, they present a stereotyped view of unmarried adults as depressed, socially isolated, unable to follow medical directions, and lacking in motivation.
NC: What can be done to eliminate this bias and make cancer therapy more inclusive?
Joan: Many medical schools already have courses on implicit bias, which focus primarily on race and gender but also include such issues as weight and smoking. Clearly, these courses should also address physicians' implicit beliefs about marital status and other living arrangements. This should also be a topic in continuing education programs for practicing physicians.
NC: What are the significance and limitations of this study?
Joan: For more than 30 years, research has shown that cancer patients who are currently married are more likely to receive surgery or radiotherapy than those who are not. The reasons offered for this discrepancy reflect social biases that extensive psychological and sociological research have shown to be inaccurate. The primary limitation of this study is that the data available relate specifically to marital status, and do not address related topics such as living alone and the absence of immediate family. Further research into bias based on living arrangements is warranted.
To conclude, the study highlighted that the benefits of marriage are highly dependent on a multitude of individual, interpersonal and structural parameters. Although the benefits of a good marriage cannot be denied, other social support systems (which are stronger in singles) like parents, siblings, friends, and community must not be undervalued either. Therefore, cancer therapists must strictly refrain from stereotyping and generalizing singles as it can lead to them being denied life-saving therapy due to biased clinical decision making. Both married and single individuals must undergo objective assessment of their support system and their capacity to undergo cancer treatment without any bias.
Neha Chauhan, Bangalore
| » Retargeting Immunity Against Oncolytic Therapy|| |
After initial treatment with standard options, most of the metastatic cancers become treatment-refractory. Immunotherapy has given a new hope in such situations, but unfortunately it works only in a small proportion of cases. Newer modalities or treatment modifications are being attempted to broaden the repertoire of anti-cancer therapeutics. Oncolytic virus therapy is such an innovation, where viruses with modified tropism are injected into the tumour or blood; these viruses specifically target and lyse the tumour cells in primary and metastatic locations by characteristically hitting the molecular alterations of tumour cells, thereby sparing normal tissue. Oncolytic viruses have multiple means of action when affecting tumour cells like activation of innate immune cells, releasing inflammatory cytokines and tumor antigens, and modulation of the tumour micro-vasculature. Till date, the only molecule for oncolytic therapy approved by US FDA (Food and Drug Administration) is T-VEC (talimogene laherparepvec), which is a modified Herpes simplex virus type-1 derived oncolytic immunotherapy for malignant melanoma. However, resistance to oncolytic virotherapy develops, when the innate immune system mounts antibodies against viruses. To evade this mechanism, scientists are trying to retarget the innate antibodies against cancer cells through a recombinant adapter fusion molecule, which consists of a tumour specific ligand and adenovirus hexon domain. There are three putative mechanisms of action of this lucrative technology. Firstly, antibody-retargeting makes the antibody identify tumour cells as foreign cells and tumour lysis occurs through antibody dependent cellular cytotoxicity. Secondly, this targeting activates the complement cascade leading to complement -dependent cytotoxicity. Thirdly, the changes in tumour microenvironment through infiltration of TILs and NK cells turn the tumour sensitive to Immune checkpoint inhibitors. In a recent article by Julia Niemann et al. in July 2019 [Nat Commun. 2019; 10: 3236] titled “Molecular retargeting of antibodies converts immune defence against oncolytic viruses into cancer immunotherapy”, early promising results have been shown in animal studies. According to the authors, although virotherapy represents a tumour therapeutic tool by itself, using an integrated therapeutic scheme comprising intra-tumor virotherapy for oncolysis and antibody induction, followed by a single dose of antibody-retargeting drug and PD-1 checkpoint inhibition to maintain and amplify anti-tumor T-cell responses may achieve long-term survival benefits. As per the opinion of Dr. S Viswanath (Senior Advisor, Medical Oncology, Command Hospital, Lucknow), “This modality seems highly impressive, nonetheless, we will be eagerly awaiting the results from further clinical trials to yield the long awaited survival benefits in metastatic, palliative, treatment-refractory settings”.
To conclude, this is a highly interesting but complex approach, wherein patient will need triple drugs including a virolytic therapy, recombinant adaptor molecule and immune checkpoint inhibitor. This will remain practically challenging, considering the physical as well as financial toxicity for the palliative patients who would have already received multiple lines of prior therapies, often accompanied by poor performance status and borderline organ reserves.
HS Darling, New Delhi
| » Self-Perceived Burden to Others Motivates a Wish to Die in Cancer Patients|| |
The perception of being a burden, or self-perceived burden (SPB), is a common phenomenon in patients with advanced and terminal illness, especially cancer. Patients have to deal with not only the physical distress of the disease process, but also various psychosocial and existential concerns and they end up anxious, depressed, hopeless, contemplating suicide and feel that they are a burden to their caregivers. SPB significantly impacts decision-making in serious illnesses about where to live and whether to prolong or withhold life-sustaining treatment and affects interpersonal relations. It is also a significant predictor of suicidal ideation and death-hastening acts.
The aim for a study undertaken by Gudat et al. titled “How palliative care patients' feelings of being a burden to others can motivate a wish to die. Moral challenges in clinics and families” (Bioethics. 2019;33:421–430.) across various centers in Germany was to analyse the thought process and intention of patients experiencing a wish to die (WTD). The feeling of being a burden to others emerged as an important theme in many interviews when investigating the motivations behind a WTD, but also independently of WTD.
In this prospective, interview-based study of WTD in patients with advanced cancer and non-cancer disease (organ failure, degenerative neurological disease, and weakness), SPB stood out as an emerging theme. Secondly, in a sub-analysis (a) the facets of SPB, (b) correlations between SPB and WTD and (c) SPB as causation for WTD, were analysed.
A total of 248 interviews with 62 patients and their family caregivers and professionals, were undertaken. Patients expressed many sorts of concerns for others, but also perceived a negative self-esteem building up. A total of 31 out of 62 patients mentioned SPB. In SPB associated with WTD, 3 constellations were found and an additional needed working out (a) WTD as a means to free others of the burden; (b) SPB was in opposition to the WTD (patients decided against hastening death to prevent being a further burden to others); and (c) both wishes for and against dying being sustained by SPB. Further, strategies patients and relatives took to counter SPB is another field work in progress.
In four more cases, the patients didn't point out their SPB clearly, but the family members who cared for them reported it in the interview. Another 12 patients mentioned a WTD without any feeling of SPB.
Of the 31 patients with SPB, 18 expressed a WTD in the present or in a future situation that seemed inevitable to them. The other 13 patients with SPB described other wishes: a wish to live, acceptance to the fact that death would come without wishing for it or other constellations not adequately clarified. Although patients described in direct word show burdened they were by symptoms or impairment of their routine activities, they rarely explicitly uttered the word “burden” for their caregivers perception. Feelings of being a burden to others were conveyed through description of events and experiences, in a broader psychosocial and spiritual context, including living conditions, cognitive functioning, preexisting couple conflicts, disease trajectories, gender issues and cultural constructs. Growing illness-related frailty and the complexity of daily activities of living influenced the patients' relationships with their family, friends, and their social contacts. New equilibrium had continually to be struck within these relationships. However, the patients perceived very limited options to contribute to a balanced relationship. They were seriously concerned that they would burden others by causing hardship in various ways for whoever cared for them. Secondly, it was found that patients spoke about SPB when they could no longer hold a positive and meaningful image of themselves within the relationship, they perceived themselves to be solely the cause of problems and disappointment.
Speaking in the same vein, Dr. Kabindra Bhagabati, (In-charge, Palliative Medicine, Dr. B Borooah Cancer Institute, Guwahati) states “In India, long and continuous treatment for cancer becomes a burden for the family members, especially for the poorer sections of society. Even though some hospitals offer free treatment with the help of local government, logistics becomes a problem. If the lone earner of the family is involved, the situation demands sustaining of family income for survival, and in case of dependents, it is the question of continuity of care. We have seen patients wishing to die instead of living like that. Social workers and psychologists can help them out in this situation.”
Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. The authors concluded that the impact of SPB on a WTD and the various meanings the facets of SPB in balancing relationships need to be worked out individually. An early palliative and narrative approach in their opinion would help.