When I was diag'nosed with breast cancer, I was working as a board-''certified oncol'ogist. The initial deci'sions most patients face ' which doctor to see, what kind of doctor to see, and at which medical center to see them ' were basi'cally non-''decisions. I knew, within an instant of my diag'nosis, who I'd ask to be my oncol'ogist, surgeon and plastic surgeon. Those choices were straight'forward, because I knew what those physi'cians were like in terms of how they cared for patients, their knowledge and other aspects of their prac'tices and personalities.
The harder deci'sions were what treatment to take, or not, for my early-''stage breast cancer. I was perhaps the most informed cancer patient who could walk into an oncologist's office. I was familiar with the dif'ferent reg'imens. I knew that adjuvant chemotherapy would, roughly and over the long haul, reduce my odds of recur'rence by a third. I was aware that, if I opted for a lumpectomy, radi'ation treatment would reduce the local recur'rence rate but was unlikely to affect my long-''term sur'vival. I under'stood that dose-''intense reg'imens were more likely to make me sick and more likely to cause problems down the road.
And yes, in the back of my head I knew that chemotherapy can cause another cancer. Did I think about that pos'si'bility? The best answer is, probably, not so much. I was coping with the present.
But that knowledge did influence the decision I made to take a rel'a'tively 'light' dose of chemotherapy. I was lucky, also, in that I under'stood my pathology. My tumor, at 1.5 cm, with a neg'ative sen'tinel node and gen'erous expression of hormone receptors, was a good-''prognosis tumor. I was 42 years old, and wanted to live for a few more decades if I sur'vived my spine surgery (another story). I chose the minimal amount of chemo that had been shown in clinical trials to reduce the odds of recurrence.
Last week, I wrote a piece for the Atlantic on how doctors and patients talk about the risks of chemotherapy, or not, and whether patients listen or nec'es'sarily want to listen. The reason I put it out there is because I've seen doctors shy away from this part of the con'ver'sation about cancer treatment. I'm a firm believer in informed consent, and in patients' access to as much infor'mation as they choose to have. If you get chemotherapy, you have the right to know about these risks, and to ask your doctor about them.
I've been there with patients who've said: 'please, don't tell me this. I can't deal with it.' Some might even con'sider it cruel to tell patients with a serious, urgent and treatment-''needing con'dition details of all the pos'sible side effects. Many ask, 'what would you do, doctor, if it were someone in your family?' And if they like and respect you, they go with your recommendation.
This kind of pater'nalism, when a doctor assesses the risks and ben'efits, and spares the patient's 'knowing' seems anachro'nistic. But it may, still, be what many people are looking for when and if they get a serious illness. Not everyone wants a 'tell me every'thing' kind of physician. What do you think?