The Oncology Podcast

Overtreatment Factors with Nathan Cherny: An OJC Meets Podcast

• The Oncology Network • Season 2 • Episode 3

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When does aggressive cancer treatment shift from beneficial to harmful? This powerful conversation between Professor Nathan Cherny and Professor Christopher Jackson tackles one of oncology's most challenging ethical dilemmas – overtreatment at the end of life.

Drawing on his extensive experience and research, Professor Cherny illuminates the complex factors driving excessive treatment, from departmental culture to cognitive biases. 

"Oncologists need to learn not only when to treat, but when not to treat," he emphasises, highlighting how treatment decisions for poor-performance status patients with resistant disease require particular scrutiny. 

The discussion reveals eye-opening research showing patients might consider additional treatment worthwhile only if it provided 12-18 months of quality life – far beyond what late-line therapies typically deliver.

Throughout the conversation, both oncologists acknowledge the delicate balance between appropriate intervention and knowing when to step back. Professor Cherny offers practical guidance for reframing hope beyond treatment response and recognising that courage exists not only in pursuing another treatment but also in saying "enough." This nuanced exploration of patient-centred decision-making provides a valuable perspective for clinicians, patients, and families navigating cancer's most difficult moments.

Join our community at oncologynetwork.com.au for more insightful discussions and subscribe to our weekly publication The Oncology Newsletter to stay informed on the latest advancements in cancer care.

The Oncology Podcast - An Australian Oncology Perspective

Rachael Babin:

Hello, I'm Rachael Babin from the Oncology Network. Welcome to the OJC Meets sister series of the Oncology Journal Club podcast. In today's episode we welcome back Professor Nathan Cherney to discuss overtreatment at the end of life with our host, professor Christopher Jackson. Why do some patients continue to receive aggressive therapies when the benefits are limited? What systemic, clinical and cultural factors drive these decisions, and how can healthcare providers and families make better, more compassionate choices? Discussing Nathan's paper on the factors that drive these extra interventions, this podcast explores the human and ethical costs of overtreatment. A 15-minute podcast that will inspire you to make end-of-life cancer care smarter, kinder and more compassionate. This podcast is proudly produced by the podcast team at the Oncology Network. We hope you enjoy listening.

Christopher Jackson:

Kia ora. Professor Cherny, it's fantastic to have you back. Thank you very much. So this paper that we're covering today is review, really, in many ways isn't it Talking about the factors that contribute to overtreatment of cancer patients at the end of life? Obviously something which is very dear to your heart from your own clinical experience?

Nathan Cherny:

Yeah, one of the things which was impressed on me in my early days as a trainee, working with Max Schwartz at Alfred Hospital in Melbourne, was that oncologists need to learn not only when to treat, but when not to treat, because there are situations with patients who've had multiple lines of therapy who have a poor performance status, with a likelihood of being more. When you give more treatment, you're more likely to harm them than to help them and unfortunately, this is still a common scenario. It's a worldwide phenomenon. The various studies looking at the prevalence of it show that it happens anywhere between 5% to 40% of patients, depending on the scenario and the setting where you're working, and it is a complex and difficult problem.

Christopher Jackson:

Yeah, I mean it's been a theme of your life is to focus on, you know, treatments or ways of interpreting treatments that actually help people, right? Yeah, we all want to do the right thing and the hard thing often is working out what that right thing is to do and to have the structures and the frameworks to achieve that. You've talked about a framework in your review as to the types of overtreatment. Should we just go over those to start with? Sure.

Nathan Cherny:

I mean overtreatment can affect diagnostics, it can affect therapeutics, it can be relative to the specific population that you're working with. So there's sorts of examples with therapeutics is giving higher doses in radiotherapy, using many more fractions that are needed, with specific populations, with frail elderly populations, using standard doses rather than dose modifications. So these are all examples of different sorts of overtreatment, but the one that we're focused on in this paper is specifically the issue of overtreatment with systemic therapy at the end of life.

Christopher Jackson:

Yeah, I mean so naturally you have a diagnosis, things like you know, PSA screening or picking up incidental cancers or carrying on with screening even for other cancers, and people have already got metastatic cancer. Lots of good examples of that. You know the word over-treatment. I think everyone objects to the idea of over-treatment. The problem sometimes is identifying it right. I mean, no one thinks you're an over-treater, in much the same way that no one thinks you're a bad driver.

Nathan Cherny:

So how do you get towards that? How do you get towards identifying overtreatment in your own practice? I think that one needs to be very circumspect in looking at one's own practice and practice patterns. Certainly, if you ask oncologists how often they overtreat, they most say very infrequently. When you ask them how frequently do your colleagues overtreat, they answer very frequently.

Nathan Cherny:

So there's obviously a difference in perception between self-perception and how you're seen by others and I think that the perception of others is often a more accurate perception. But be that as it may, there is a differential diagnosis and there's a difference between trying a further line of therapy with a good performance status patient or sending them off to go into a phase one study with a low likelihood of benefit. But because they've got a good performance status, they've got physiological reserves. But when you're dealing with someone who is now frail, with a poor performance status, who's got established very resistant disease, this is a different situation and often this evaluation is as to how fit and how well the patient is has some degree of subjectivity in the evaluation and also you know how close to death patients are. There's also we know that oncologists are only fairly good prognosticators and that we're sometimes over-optimistic about our patients' reserves.

Christopher Jackson:

Absolutely, and you mentioned as well that we've got the tendency to remember the cases that went well, because they're the ones that fill up our outpatients clinics. We're reminded of the times we get it right that's right and perhaps of the times we fail. Do you think that over-treatment's becoming more prevalent, with patients becoming more informed and more access to social media, greater marketing, direct consumer marketing?

Nathan Cherny:

I think that the expectations of cancer treatments are higher and I think that they are higher than the reality in many situations. So because patients have high expectations, because physicians and oncologists have high expectations of many of the new treatment modalities, particularly targeted therapies and immunotherapies, we know that many of these are also being overused at the end of life and there's been good data collected on that in recent years, particularly by the group at MD Anderson.

Christopher Jackson:

Yeah, they're also least toxic, though, right, you know, the targeted therapies and the immunotherapies are least toxic.

Nathan Cherny:

Not necessarily so. I mean, the toxicities of many of the new targeted therapies are quite substantial. When I look at our inpatient ward, I'd say at any one time a third of the patients that are in are in with complications of their immunotherapy, and I think that there is a tendency to underestimate the potential harms of these treatments as well, and we've seen people who's been quite wiped out by either of them.

Christopher Jackson:

Yeah, so you've got some metrics in this. We're familiar with death within 30 days of chemotherapy, or 14 days in the American setting is what they've put in there and the research shows that's very strongly related to tumour type right, with some cancer types having a higher rate of treatment at the end of life, which does go to the difficulties with prognosticating.

Nathan Cherny:

It's tumour type, it's age, it's gender as well. So people tend to be more aggressive at the end of life, with young people with hematological malignancies somewhat less in solid tumor than hematological malignancies In solid tumor. Oncology we see it across the full spectrum of illnesses, particularly in I'd say particularly in lung cancer, particularly in sarcoma therapies, particularly with pancreatic and gastric cancers, where we know the outcomes after second or third line therapy are very, very poor and yet quite a lot of patients are pushed almost to the end of life.

Christopher Jackson:

You mention as well, certainly, cultural and departmental issues. So one of the things that fascinates me is the admission to intensive care. So our intensive care and my hospital would not take somebody who has end-of-life or trajectory. They would take people who are on adjuvant therapy or have a reasonable chance of salvage. And I think in my last 20 years I've had four or maybe five of my patients go to the ICU in total. That's in all scenarios, so it's uncommon in our setting.

Nathan Cherny:

I want to say that the issue of the culture of care is not so much about intensive care, but it's about each individual department has its own culture, often led by the clinical leaders in the department, and when you have clinical leaders and opinion leaders who are very aggressive, looking for further lines of therapy for patients approaching the end of life, that's going to impact downstream, particularly on the trainees and to other colleagues, and this is what I talk about. This is what I mean about the culture of care. We have a clinical leader who emphasises the importance of knowing when not to treat. That also influences the culture of care. So one walks to find balance between being adequately aggressive and not being nihilistic and not being over aggressive.

Christopher Jackson:

So what would your advice to young trainees and early career oncologists be who are in a department where they think that sometimes their seniors are perhaps going beyond the evidence and offering one more treatment when perhaps they should be pulling back? I think two things.

Nathan Cherny:

One is when I consider the issues of role modelling, I encourage my residents to look critically at their role models, to learn the things that you would like to emulate and to look at behaviors with a critical eye and learn what you would not want to be doing and, when they see the adverse consequences of overtreatment, to learn that this is really causing patient harm.

Nathan Cherny:

And there's a balance issue, but certainly there are power issues within departmental structures. We use our multidisciplinary meetings as places to vent these issues out, looking at the pros and cons of a further line of therapy, sometimes arguing these very aggressively. One of the biases that often affects group behaviors is the bandwagon effect, where it just becomes standard what further treatment can we possibly find? Let's look at the phase two data or what recent phase one data there is. Almost with what's called a therapeutic imperative like this, it's obligation to find another treatment. Then the number of treatments that are going to help is finite and you're going to get to a point of diminishing returns where the likelihood of harm outweighs the likelihood of benefit, and that's when you're going to stop.

Christopher Jackson:

At an individual patient level. These can sometimes be really challenging.

Nathan Cherny:

Right the hard part of work as an oncologist are these dialogues and dealing with patients' justifiable fears fears giving them meaningful and accurate information as to what the likelihood of benefit and what the likelihood of harm is and, if there is to be a benefit, how long it's going to be a benefit for One of the issues we bring to the attention of the readers the studies of patients who have previously gone through therapy and asked them how much added life would they want to justify another line of treatment? How much added life would they want to justify another line of treatment? And in some of the studies, what would justify another line of treatment is another 12 to 18 months of good health. And that is so far from the reality of what can be offered with third, fourth or fifth line therapy that if the patients had the information as to how much real benefit there's likely to be, that they would often decide this is not in their interest.

Christopher Jackson:

Yeah, you mentioned that in your paper that for colorectal cancer something like 33 months of extra life would be needed I think it was which is pretty much no treatment in medical oncology. Gi cancer offers that. So I found that challenging to my biases, nathan. So I had to really think hard on that one and the other factoid that came out as well, the fact that came through in the paper. You go back to primary reference, but you talked about how centres that have got higher treatment intervention rates actually have no better outcomes than those that don't have the same high treatment intervention rates, which ran counter to my assumptions and I found that also really interesting as well.

Nathan Cherny:

This is another work from the MD Anderson group. They looked at data from a very large data set, a flat iron data set, where they found those centers with the highest and the lowest prevalence of treatment in the last two weeks of life and they can prospectively compare the survival outcomes and there was no difference.

Christopher Jackson:

Is that of all patients? Yeah, fascinating. Yeah, yes, one of the patients who I looked after earlier in my consultancy career still sticks with me today is a young guy who had a diffuse large B-cell lymphoma very chemo-sensitive, but E coli performance status3, and had liver dysfunction with it and his wife was 34 weeks pregnant. And we talked about, you know, no treatment and end-of-life care, poor performance status, etc. Etc. And he said, look, I'm prepared to go through anything because I want to hold my baby. And he opted to have treatment and he died in hospital. But he got to have his daughter, who's now 14, got to have a photo of her dad holding her, and so the value of that extra six weeks of life of that young guy was meaningful for him, although he would have shown up in my death within 30 days.

Christopher Jackson:

Stats, and it's still one I wrestle with to know if that was the right thing to do or not Many years later when you hear about these sorts of, when you challenge yourself about the idea of over-treating at the end of life. But it strikes me that the proportion of patients you treat within 30 days of death shouldn't be zero. There will be some who would be appropriate to do so and that if you have an absolute rule, you'll miss out on an opportunity for some. So it's getting that judgment again, right, isn't it?

Nathan Cherny:

But that's individualised, goal-focused care, with a patient who had informed consent, who knew what the situation was, who knew what the odds were, and that's fine. And one of the things we talk about is that there are going to be some patients who, despite having all the information, will want a trial of therapy, and that's okay. There needs to be an agreement when the trial ends, and the trial ends would be if the treatment is causing harm and if it's not working. Whether that young guy survived to hold his baby because of the treatment or despite the treatment, that's an unknowable.

Christopher Jackson:

Yeah, you can't get to run a randomized trial on an individual canine. Unfortunately, Some people call work like this nihilistic. What's your response to that, Nathan?

Nathan Cherny:

I think that there is a difference with these patients who have a very poor performance status at the end of life. You know a patient and I have no small number of them myself who are still fairly robust despite multiple lines of therapy. You know, try to find something else for them is a reasonable option and it's one which I'll often pursue myself and sometimes I'll say look, let's get another opinion to see if someone else has a better idea or a good phase one study. So I think there's an issue of appropriate patient selection which is really important.

Christopher Jackson:

Yeah, that's critical, and what's also really clear is your own compassion and humanity, which comes through in all of your work, nathan, and I really liked your conclusion towards the end, where one of the key points you talk about is how to reframe hope. Reframe hope not for treatment response, but reframe hope for a good day, quality of lifetime with family away from hospitals, and refocus people's goals on things that matter to them.

Nathan Cherny:

Another thing that I often talk to patients about is courage. Just like we often find that it's the courageous patient who's prepared to take another line of treatment, so there's a lot of courage also in saying enough, this is not likely to help me. Furthermore, this is just compromising my quality of time and taking time away from my family, and it takes courage to say I'm not going to take any further treatment. And in these discussions I say don't make a decision now. Okay, this is too important. Let's get together in another day or two, after you've had time to digest a lot of these things and to rediscuss this, and then we'll make a final decision together. Because I think there's a tendency of people to be impulsive, to say, of course, I want another line of treatment and by impressing that this is a non-trivial decision that deserves due consideration is a point worthy of emphasis.

Christopher Jackson:

Well, look, I think this is a fantastic paper. I encourage all the listeners to check it out. In the show notes We've got a link to the paper which is included there. It's open access there. Nathan, you clearly are very grounded in the principle of patient-centred care and have done the very best for your patients. Not only do you want to do the best for the people who trust you with your care, with their care, you also look to hold yourself accountable and help us all hold ourselves accountable. You know, when we're looking at treatments through the ESMO score and through, you know, frameworks such as this to help us really genuinely reflect on things, and that's just a massive contribution to critical, reflective practice and, hopefully, helping people around the world. If there was one thing that you would want a reader to take away and do differently tomorrow as a result of your paper, what would that be?

Nathan Cherny:

It would be to recognize that this is a really complex situation between the cultural pressures, psychological pressures, to be self-aware of your own cognitive biases, like optimism bias and confirmation bias, and to say don't make these decisions or recommendations reflexively. Take time out and think about it and think about the appropriateness of it before you jump in with the next recommendation.

Christopher Jackson:

Professor Nathan Churney, thank you so much for your time compassion, intelligence, warmth, care, commitment, hard work and you're an Aussie.

Nathan Cherny:

And you're very kind, despite being a Kiwi. We could all enjoy our vigil mate.

Christopher Jackson:

Thanks so much for coming on the show, nathan. I hope to speak again soon. Great, okay, see you later.

Rachael Babin:

Thank you for tuning in to the Oncology Journal Club podcast, proudly brought to you by the Oncology podcast, part of the Oncology Network For healthcare professionals. Seeking regular news updates and insightful discussions, we invite you to join our community at oncologynetwork. com. au. Your free registration includes a complimentary subscription to our weekly publication, the Oncology Newsletter, a valuable resource to stay updated on the latest advancements in the field. We value your input and welcome your feedback and paper recommendations via our social media channels, email and website. Your insights help shape the conversation and drive the direction of future episodes. This is Rachael Babin signing off for the Oncology Journal Club podcast.