"How Much Does Chemotherapy Improve Survival?"
Though we often hear new cancer drugs described as game-changing
breakthroughs, most afford much more modest benefits.
In my last video, I quoted a recent editorial in the
Journal of the National Cancer Institute suggesting that the majority
of new cancer drugs don't deliver clinically meaningful benefits at all.
At least when they are later proven to be ineffective,
they're pulled from the market, right?
No! Even when postmarket studies show the new drugs to have
no clinically meaningful benefit compared to not just older drugs
but compared to nothing, compared to a sugar pill,
most chemo drugs retain FDA approval and remain on the market,
even at the same ridiculous prices. In fact, the most expensive drug
they looked at, the one costing $169,836 a year,
did not improve overall survival at all, and actually worsened quality of life.
$169,000 just to make you feel worse with no benefit.
Why pay a penny for a treatment that doesn't actually help?
And even when they do improve survival,
what does that actually mean?
Currently, the trend is for Big Pharma to design large trials that may detect
statistically significant, but often trivial,
differences in survival endpoints.
For example, check out this famous trial.
Adding this second drug, erlotinib, to gemcitabine for advanced
pancreatic cancer significantly prolonged overall survival.
Yeah, they suffered more side- effects, but we're not just talking
about tumor shrinkage. They lived significantly longer.
The placebo group only lived 5.91 months, whereas
the added drug group survived all the way to 6.24 months?
Wait a second. They only lived a third of a month longer?
That's just 10 days.
All the side-effects and expense for an average of just 10 days?
That's why doctors shouldn't use the statistical jargon ---
significant improvement in survival ---
while informing patients about benefits of new treatment.
When patients hear the word "survival,"
they're not thinking about a week and a half. If you put
all the new chemo drugs together approved over the last dozen years,
the average overall survival benefit is 2.1 months.
Now look, two months is two months, I don't want to downplay that, but
time and again, surveys have indicated that patients expect much more.
Incredibly, about three-quarters of patients with metastatic lung
or colorectal cancer did not report understanding
that their chemo was not at all likely to cure their cancer.
I mean, that's the primary treatment, but the chemo's not curative;
it's just eking out a few extra weeks or months.
Why weren't the majority of patients told that?
It's not that they were being over-optimistic,
explained the researcher. They were under the mistaken belief
that the treatment offered a chance of cure when it in fact didn't.
That deprives patients of the opportunity
to weigh the risks and benefits and make their own decisions
about their own body.
If you ask cancer patients, most want at least half a year
to stomach the side-effects, which suggests that most
cancer patients might not choose chemotherapy
if they knew how little they'd actually benefit.
But look, everyone's different. One patient they interviewed
said living even one week longer would be worth it;
whereas another said they wouldn't even want to do chemo
for two extra years of life; they wouldn't want
anything to interfere with the quality of the time they had left.
Either way, people deserve to know the truth.
I find it telling that oncologists and cancer nurses themselves
express less willingness to accept intensive chemotherapy,
given the associated toxicities.
Most chemo drugs are cytotoxic, meaning they work by killing off
cancer cells, but they also kill off some healthy cells
as collateral damage, which is why they can damage
our nerves, cause irreversible heart failure,
slough off the linings of our gut, or damage your immune system.
Drug companies frequently downplay the risks, though, for example,
describing this breast cancer drug as having acceptable side-effect
profiles for most patients, or this pancreatic cancer drug as having
a manageable and mostly reversible safety profile.
These were studies published in top medical journals.
Naturally, readers would take these statements to be true.
However, if you actually look at the data,
the number of serious, even life- threatening side effects was double,
or even five times higher on the new breast cancer drug.
And the manageable and mostly reversible side-effects
evidently weren't referring to those who were killed by the drug.
I like how they even included like a cheat sheet.
Acceptable toxicity. Acceptable to whom?
Manageable? Serious events and deaths can never
be considered manageable.
And feasible? Who would sign up for a drug whose toxicity
could only be described as feasible?
Favorable? Compared to what?
Tolerable? That's for the patient to decide.
And any drug that kills people can hardly be considered safe.
Still, patients may very well consider it worth the risk.
For some cancers, we've made tremendous strides.
Testicular cancer, for example.
There is greater than a one in three chance that chemotherapy
could enable you to survive at least to the five-year mark.
The same with Hodgkin's disease, a relatively rare form of lymphoma.
But even when researchers tried to err on the side
of over-estimating the benefit, for most common cancers —
colon, lung, breast, and prostate —
the chances appear to be more like 1 or 2 percent.