Enough

Zeke Emanuel wrote an interesting piece in the Atlantic not so long ago on why he wanted to die at 75. It was an interesting exposé, and one that (at least at first) can take you off guard. Seventy-five doesn’t seem very old, particularly these days, where the average life expectancy in OECD countries is over 80. As a society, we often wish for long lives and certainly have invested much time, energy, and money into unlocking the key to longevity. Particularly as cancer physicians and researchers, we are often enthralled with novel therapies that could potentially extend life, and love chasing significant p-values in survival curves for our patients. As advocates, like the American Cancer Society, “we believe every birthday . . . is a victory.” Should we be adding the qualifier “unless you’re older than 75”?

Zeke’s article gave me a lot to think about. In particular, it made me think about at what point one should say “enough . . . no more”-–no more mammograms, PAP smears, PSAs, and colonoscopies. At what point should we stop screening? The data fall short after 75, but in my mind, the answer warrants more thought than the simple rote application of data from randomized controlled trials.

There is no question that there is tremendous value in screening to find cancer early-–but only if you are in such a state of health otherwise that you would want it treated. I’m not sure there’s an age limit on this. There are 80 year olds who run marathons, and 60 year olds who have so many medical problems that a small focus of cancer would be the least of their worries and treatment would carry more harm than good. Either way, however, one needs to personalize the decision of how much is too much.

Patients who already have advanced cancer also must ask themselves when enough is enough. Do you take the new expensive therapy that causes terrible side effects, but carries the hope of extending your life by a few weeks? Or does opting for a less-aggressive route yielding improved quality of life mean that you are “selling out,” “quitting,” or “giving up”? I thought about the studies on palliative care that demonstrated both an improvement in quality and quantity of life, and reminisced about some public perceptions of such approaches as “death panels.” Perhaps we’re not quite ready to give up on what Zeke calls the “American immortal” viewpoint. . . .

Or perhaps we look upon the cost savings of such approaches with disdain, in the same way you look at sale items and wonder what’s wrong with them. There is no question that the more progressive viewpoint is cheaper. We spend an average of $962 million in breast cancer screening annually in the elderly, with an average age is 77.3 years; yet, the data for improvement in survival in this population is limited. We continue to seek out high tech diagnostics that add tremendous cost, but the incremental benefit is less clear. And we continue to spend $50 billion/year for doctors and hospital visits in the last two months of life, although we know that a significant proportion of this care is futile. At what point will we, as a society, say “enough!”? It seems we all want to live forever-–spare no expense. 

So what about me, you ask? Do I want to die at 75? I’m not sure I have a specific number of birthdays I’d like to have before my inevitable demise, but I am sure of this . . . when the incremental cost (both in financial and human terms) exceeds the incremental benefit in terms of my overall health and happiness, I too will say “enough.”

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