KB is a 67-year old Indonesian — with a history of heavy smoking for some 50 years. About 3 months ago, he had fevers and started to cough; sometime with white phlegm and sometimes just dry cough. He also lost a lot of weight.

He went to see a doctor in a private hospital. X-ray and CT scan indicated:

• a 9.8 x 11 cm mass in the right upper lobe.
• a non calcified 1.2 cm nodule in the left lower lobe.
• small (1-1.5 cm) mediastinal lymph nodes.

A FNA of the right lung mass done on 17 March 2015 confirmed lung cancer, likely an adenocarcinoma, Stage 4.

KB was asked to undergo 8 cycles of chemotherapy. The total cost of the treatment is about IDR 120 million.

Chris: Did you ask the doctor if chemo is going to cure your father’s cancer?

Daughter: Can only extend his life.

C: So what do you want to do now?

D: No, we don’t want to do chemo.

Questions to ask

The above are the standard questions I often ask patients when they come to seek our help. Almost all patients were told that in spite of their terminal cancer, they should undergo chemotherapy to either stop the cancer from spreading or to prolong their life. Chemotherapy is also said to improve quality of life.

Frankly, I find these justifications rather hard to swallow.

Ask these questions:

1. Can chemotherapy really prolong life? Many patients told me that they would not go for chemo because their relatives, friends, parent, etc. had chemo and died. To these people chemo did not prolong life.

Nose (NPC) Cancer: Chemo and He was Dead Six Months Later – Why?

Dissecting Chemotherapy Part 7: Avastin + Alimta Nearly Killed Me (after saying this, the patient died).

Of course, some patients benefited from chemotherapy and remain alive but NOT without enduring severe side effects.

I googled “does chemotherapy prolong life” and here are some interesting answers I got.

One person asked: Does chemo work? I don’t think it will prolong my life, and most likely kill me? He got the following responses.

• I was a cancer chemotherapy specialist doctor for twenty years.I treated thousands of people with various combination chemotherapy regimens. I don’t think I killed any of them with the treatment – though over two thousand died from their cancers. I often thought it would be better to not use chemotherapy in situations where no cure had ever been achieved with drugs – pancreatic cancers, advanced non-small cell lung cancers, many brain malignancies, etc. I spent a great deal of time trying to talk some patients out of taking chemotherapy. In the USA, many people will not accept the ‘supportive care only’ option no matter how carefully it is explained that chemotherapy has never cured some types of advanced malignancies.
• Nobody can or will give you any guarantees with chemotherapy.Why do you think it will most likely kill you? What evidence are you basing this on? … Some people conclude that the treatment is worse than the disease, and myths about people being killed by chemo bolster this belief. It isn’t always effective. But in those cases it is the cancer, not the treatment, that kills the patient – they have died in spite of treatment, not because of it. Distressed relatives sometimes look for something or someone to blame, and some conclude that it was the treatment that killed the person. People with aggressive and advanced cancers who agree to chemotherapy aren’t duped; they do so in the full knowledge of these facts because they have a life-threatening disease and this is their best chance. Chemo and other cancer treatments are not perfect, very far from it.
• No, if chemo worked there would be fewer people dying, and in most cases it’s the “therapy” rather than the cancer that killed the patient. The drug severely damages the liver and ravages the immune system.
• Wow, what a question. It’s a personal choice. You should research it very carefully, all positive and negative opinions about it.I know that I would never choose chemo. I would be willing to have surgery, and I’m not sure about radiation, but chemo, never. We are all going to die anyway, and we should die the way we want to and not let others tell us how. Chemo would take away my will to live, so what’s the point?

Another person asked: Will Chemo buy me more time ?? Anyone, Ideas? I was diagnosed 6 weeks ago with stage IV non small cell lung cancer with a tumor in left lobe, 1 brain tumor and several swollen lymph-nodes. I was told today I could expect to live 1 year. Beyond 12 months will be in God’s hands. I had targeted radiation on the brain tumor. I have started chemo and it has made me feel horrible. I’m short of breath and I little tired. But when I take the Chemo I feel like it’s speeding up my clock. What I mean is I cannot help but wonder if the side effects of the chemo will steal more days of my life than this dreaded cancer. Close friends and family are telling me to stop killing myself with chemotherapy!!! Has anyone out there been thinking the same way? I’m so afraid of losing the ability to function normally daily.

The following are some comments from readers.

• My mother struggled with this decision when she was diagnosed with leukemia. Hers was a very aggressive form that didn’t respond well to treatment. Her doctor then wanted to start her on a very aggressive chemo regimen called CVP, which has tons of nasty side effects (it is one of the regimens they give when getting patients ready for bone marrow transplants). She was torn with the decision of what to do. I had already told her that if I had to choose between quality and quantity, I would rather have her feeling good for a month, than a year of her being miserable. When the decision came, she asked me what she should do (I am an only child). I told her there was no way I could answer that. It was her decision, her body, her life. I told her that I would love her and support her in whatever decision she made. She went to church regularly, so I told her to pray about it and she would find the answer. In a few days, she told her oncologist that she wanted to suspend her treatment. She never started the aggressive chemo, and I cared for her until she passed away.

  Now as I watch my husband go through chemo for lung cancer, and see how he suffers with it, I can even more clearly see how my mom made the right decision for her. My husband is a different personality, therefore he has a different approach. No one can blame you for the choice you make at this point. It is yours to make. I know you will make the right choice for you, and I pray you find peace as you make that choice.

• I’m sorry that this disease as come in to your life, yes it SUCKS!!! I pray that you will feel better soon. My dad is 55yrs old and was diagnose just about a year ago, and yes they told him he’s terminal and only had 6 months to a year to live. Is going to chemo worth it?? That just depends on YOU ….
• My wife, 53 years of age, was diagnosed in May 2011 with two tumours in the lung and three brain mets. We were told ‘months rather than years’! Decided on no radiation treatment as there is no conclusive proof that it extends life. Began chemo at the end of June (Cisplatin and Pemotrexed). The first two scans on the lung showed a reduction in the tumour size each time. The third lung and brain scan in December showed that the lung tumours were continuing to shrink and one of the brain mets had disappeared completely. The oncologist told my wife ‘that without this treatment you wouldn’t be here now’. My wife has had a pretty horrid time with nausea and vomiting … Fatigue is another problem, along with a sore mouth but she hasn’t lost her hair. She’s been working in our garden, and has considered going back to work but I think the constant need to have naps might prevent that. Overall, very happy with the way things are going.
• It’s definitely your choice. Chemo is doable and not everyone has a horror story to tell about it. For me the worst part was the fatigue. Maybe I’m fortunate that I have no long term side effects. No doctor should be telling you that you only have a year to live, as they’re not God and don’t know how you’ll respond to treatment.
• My husband, Jerry, was diagnosed with stage IV lung cancer the last week of Jan. 2011. When his oncologist saw him for the first time he said “I can’t cure you, but I can give you an extended amount of time, and a better quality of life”. After 7 weeks of chemo and radiation the tumor that was the size of an orange is now the size of a pea and is inactive. The other four active spots in his other lung are gone as is the spot on his lower neck and lower spine. His oncologist now is saying he can have surgery to remove the dead tumor (we have till Jan. 26 to decide if he wants to go through surgery as he is 74 years old). Please don’t believe everything your doctors tell you. With your own determination, the help of all medical options, and with prayer, anything is possible.
• My sister just passed from non-small cell lung cancer (BAC). She was on Alimta as her chemo drug. As soon as the dr. gave her a time frame of life expectancy she went downhill. We had her on supplements, vitamins, etc. There are tons of alternative treatments if you just type in alternative cancer treatments you will find tons of treatments. Most of the alternative treatments you can do at the same time as chemo. I believe all green is the way to go – I could not get my sister to try that.
• The first line of chemo can be very difficult – I won’t sugar-coat it. But they should know pretty quickly if it’s working or not, and may be able to adjust your dosage if the side effects are too hard. When I got the first scan back that said the chemo had shrunk my tumor by almost half, I decided I could handle it for awhile longer. It was worth it. The second line of treatment was much, much easier My hair grew back, the side effects were only 2 or 3 days and very manageable. That chemo worked so well that all signs of active cancer have disappeared, and I was able to stop chemo and do a watch and wait. I am now 2 1/2 years past my Stage IV diagnosis, and doing great.
• If only we could clone ourselves, try various treatments, then pick the one that worked best.
  I was diagnosed in August with stage IV NSCLC with a dozen mets to ribs femur pelvis, skull, and spine.
  I had 2 week radiotherapy to the skull, which was effective in stopping progress, and headaches.
  I cancelled my scheduled Chemo after testing showed I had no identifiable mutations, So was not eligible or targetted therapy. I have adopted a strict vegetarian diet, I meditate and do Gigong. I have 5 fresh vege juices a day, and take a few supplements. A herbalist specialising in traditional medicine has made me a tonic I take 3 times a day. This is my alternate chemo.
  My latest scan showed no new cancer and a mild progressive enlargement of the existing ones.
  I feel fine, no one would suspect I was ill. Apart from the 2 weeks Radio I have spent VERY little time in the hospital environment
  I had chemo 30 years ago for leukemia, so it does not worry me. I do not believe chemo offers me much advantage. It will also do a huge amount of damage to my own defense system.
  Maybe I am just fortunate to have a slow growing cancer, or maybe what I am doing is right. I will never know. But I am so happy i gave my body a chance to figure this out for itself before embarking on toxic intervention. Chemo might be the right thing for me down the track, but for now my body’s immune system has a chance to catch up to the disease and maybe stop it. Myself, my wife and my oncologist are very happy with my situation and see no reason to change, at this stage.

Many thanks to each of you who took the time to give me your opinions. I will re read your notes and think carefully. My Dr was intent on me starting chemo full speed ahead. To be honest I wonder if money is a driving force in the push for so much random chemotherapy. I wonder how they select a drug for each person. I would like be sure it’s not eny meney miney mo —- let’s try this one to see if it will help her. They gave me so little information I have had to hunt the internet for details … Poison is poison —- and poison kills right?

2. If chemo prolongs life, don’t you want to ask ” prolong by how long or how much” – – days, weeks, months or years?
3. Next question, Prolonging life at what cost — in terms of suffering and money?

Drs Tito Fojo and Christine Grady in the USA appear to swim against the current too. They wrote an interesting paper: How much is life worth: Cetuximab, non-small cell lung cancer and the $440 billion question. The first author is from the Medical Oncology Branch of the National Cancer Institute, Bethesda, USA, while Dr. Grady is from the Clinical Center, National Institutes of Health, Bethesda, USA.

This is what Dr. Fojo & Grady wrote in their paper:

1. In the United States, Treatment with Erbitux treatment for lung cancer costs an average of US$80,000 (to prolong life by 1.2 months), which translates into an expenditure of US$800,00 to prolong life of one patient by one year.
2. The median US household income is US$50,233.
3. The cost of Avastin treatment is US$90,816 and that is said to prolong life by 1.5 months.
4. The cost of Tarceva treatment is US$15,752 and it is said to prolong life by 10 days.
5. The cost of Nexavar treatment is US$34,373 and it is said to prolong life by 2.7 months.
6. Greater than 90% of the anticancer agents approved by the FDA in the last 4 years cost more than US$20,000 for a 12-week treatment.
7. These examples challenge the oncology community to address some serious questions:
8. What should count as a benefit in cancer?
9. What is the minimum amount of benefit needed to adopt a therapy as the new standard?
10. Is 1.2 months of additional life a “good” in itself?
11. How much should the quality of that 1.2 months matter? Or the cost?

(Take note: none of these drugs cure cancer. They just prolong life by just a few days or months)

In concluding their paper, Dr. Fojo & Grady wrote:

• The all too common practice of administrating a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged.
• In cases where there are no further treatment options, emphasis should be first on quality of life and then cost.
• For therapies with marginal benefits, toxic effects should receive greater scrutiny.
• We must deal with escalating price of cancer therapy now.
• The current condition cannot continue … the time to start is now.

For more read:

1.  Dissecting Chemotherapy Part 4: How Much Is Life Worth? Erbitux for Lung Cancer

2.  Are Medical Bills Killing Patients?

3.  The cost of cancer drugs 

What about the side effects?

Read this research paper on chemo-radiation. http://www.oncologynurseadvisor.com/chemoradiotherapy-prolongs-life-for-older-patients-with-lung-cancer/article/245291/

Median overall survival for the chemoradiotherapy group was 22.4 months, compared with 16.9 months for the radiotherapy-only group. This means chemotherapy prolongs life by 5.5 months.

Although chemoradiotherapy was well tolerated, grade 3 and grade 4 hematologic toxic effects were more prevalent among those patients:

• Leucopenia occurred in 63.5% (61) of the chemoradiotherapy participants, but in none of the radiotherapy patients;
• neutropenia in 57.3% (55) of the chemoradiotherapy patients and none of the radiotherapy patients; and thrombocytopenia in 29.2% (28) of the chemoradiotherapy patients and just 2.0% (two) of the radiotherapy patients.
• Grade 3 infection also was more common with chemoradiotherapy (occurring in 12.5%, or 12 patients) than with radiotherapy (4.1%, or four patients).
• Incidences of grade 3 and grade 4 pneumonitis and late lung toxicity were similar between groups.
• Seven treatment-related deaths occurred, in three chemoradiotherapy patients (3%) and four radiotherapy patients (4.0%).

No thanks to chemo

In this case, KB decided not to go for chemo. The choice is easy to make. The treatment is going to cost him IDR120 million or RM 33,171 — to prolong life with no cure. Then there are the side effects to contend with. The daughter said, My father would not be able to stand it.

Yes, chemotherapy can make you feel nauseated and make you throw up. It can make your hair fall out. It can temporarily depress the immune system. It can cause bleeding complications, such as GI bleeding. It can cause kidney damage. It can cause heart damage. It can cause lung damage. it can cause nerve damage. It can make you lose weight. It can even result in your death from complications. In short, it is not something to be taken lightly. Unfortunately, the disease it’s meant to fight is a formidable foe indeed. It is your own cells, and often the difference between the toxicity of chemotherapy against the cancer and against normal cells is all too often not that great. http://scienceblogs.com/insolence/2009/05/20/chemotherapy-versus-death-from-cancer/

4. Does chemo really improve quality of life?

Chemotherapy is the primary treatment approach for metastatic … lung cancers. Although the treatment can prolong life—by weeks or months—it is not likely to produce a cure. While chemotherapy may prolong life and provide some relief from symptoms of disease, it is also associated with substantial side effects. Patients facing incurable cancer must weigh the risks and benefits of a treatment that will not cure their disease, but could prolong their life. Unfortunately, the reasons for choosing chemotherapy treatment in the face of incurable disease may be unclear to patients. http://news.cancerconnect.com/patients-with-advanced-cancer-may-have-inaccurate-expectations-of-chemotherapy/

Our advice

• As you can see from the above, different people have different perceptions about chemotherapy –confusing indeed. Eventually it boils down to, It is all about your own choice! Do what you feel comfortable with… follow your heart! There is no definite answer, we are each different and for some chemo works and for some others it does not.
• Referring to this case (and many others like this), I have this advice: If you don’t want to do chemo, why do a biopsy?

Read more:

1.  Lung Cancer: Why do a biopsy when you don’t want to go for chemotherapy?

2.  The Truth About Biopsy