Amy Berman

I have been celebrating Breast Cancer Awareness month. This isn’t just because I had the good fortune to celebrate my birthday in October, but because one year after being diagnosed with a terminal illness and choosing to treat it non-aggressively, I feel great. I have less pain than I did one year ago. The shooting pains I often felt last year in my right breast have almost entirely vanished, thanks to my hormone-suppressing drugs. My lower spine—the site of metastasis—aches only occasionally, and only when I overdo it. If I get plenty of rest and fluids, eat right, and avoid standing for long periods or lifting heavy objects, I remain pain free. Although I may take a few more breaks than I used to or find myself more tired at night, I can still fill each day with meaningful activities, just as I always have.

It may sound odd but—honestly—I am living with Stage IV cancer and it’s been a great year.

Yet while celebrating my unexpected and very welcome happiness, I cannot help but think about others living with cancer and other serious illness this month. My experience is atypical, and not just because I chose a palliative, non-aggressive treatment. I am atypical because I am in my fifties. Most cancer patients—63 percent, in fact—are over age 65. This means that most cancer patients aren’t suffering only from cancer, as I am. Most are also simultaneously coping with other chronic diseases, such as diabetes or congestive heart failure, making it more difficult for them to tolerate debilitating treatments. And for some older adults, their health status before the cancer diagnosis may challenge their recovery.

Because cancer is primarily a disease of aging, we shouldn’t be thinking pink for Breast Cancer Awareness month—we should be thinking silver.

I shudder to think of how I would be feeling had I not been an informed patient, able to fully participate in my own treatment decisions with the help of my medical team. Had I been steered into aggressive treatment, I would likely be recovering from painful surgery while incapacitated due to the overwhelming fatigue, pain, and nausea that go hand in hand with radiation and chemotherapy. If patient-centered care can do so much to keep the quality in what remains of my life, how much more important is patient-centered care for older adults facing not only a terminal diagnosis, but also the presence of one or more chronic diseases? Older adults need care tailored to their individual diagnosis, health status, goals, and beliefs long before they grapple with terminal illness such as mine.

Thankfully, I am not the only one concerned about this issue. The Raise the Voice campaign, an initiative of the American Academy of Nursing, recently hosted a Critical Conversation on best practices in advanced care planning and decision making. The organizers gathered nurse and physician experts in advanced care planning to share best practices, and also included a nurse who could serve as a patient voice. That was my role. When I had the opportunity to speak, I noted that even though death is a common occurrence—2.4 million Americans die each year—conversations around end of life care remain uncommon.

This seems strange to me. We are consumers of health care.  In most other areas of our economy, our consumer protection laws afford us safeguards.  Health care is, ultimately, a product that we all have to buy, either directly or indirectly through our insurance companies. Yet when we are making the most critical decisions about our health, we are not routinely guaranteed as patients to have full information about our condition and all possible treatment approaches.  The decisions are left entirely to the discretion of the doctors and hospitals patients use.   And while some health care providers integrate the patient and family in the planning process, we are guaranteed a more full disclosure when buying a house than when battling serious illness.

I believe disclosures about treatment for serious and potentially life-limiting illness should be required. Conversations about the end of life are difficult, but not impossible. Doctors, nurses, and all health professionals have more and more tools at their disposal. We can help patients choose a health care proxy and fill out the POLST form, as my oncology center, Maimonides, does so well. Many organizations are now providing training for providers to help them learn how to approach end of life conversations with their patients, such as the End-of-Life Nursing Education Consortium (ELNEC) led by the City of Hope and the American Association of Colleges of Nursing. At the Raise the Voice meeting, Suzanne Prevost, President Elect of Sigma Theta Tau (the Honor Society of Nursing) and Associate Dean of the University of Kentucky, shared an interesting approach to helping patients understand the differences between treatment options. In a small study, researchers showed terminal cancer patients a video that included patients who chose aggressive care and patients who chose palliative care. The images were neither shocking nor graphic. After seeing the video, many patients who had intended to choose aggressive care changed their minds and chose palliative care.

I am not saying, of course, that palliative care alone is always the right choice. I just believe that patients deserve to make informed choices. All I ask, as Breast Cancer Awareness month comes to a close, is for providers and policymakers to understand that every person experiencing cancer or other serious illness deserves an opportunity to choose a treatment approach tailored to his or her beliefs, hopes, and tolerance, based on the diagnosis, the likely course of the disease, and the chances for survival. Think about the older adults in your life. Would you want them to have a say in decisions that affect how they live for their remaining days and how they die? If we can all “think silver,” perhaps we can make health care better for older Americans.  Here’s to another good year.  Cheers.

Sixth in this series [from the health AGEnda blog]:

• “Can the Blind Lead the Seeing?”
• “Making Hard Decisions Easier”
• “Death Panels and Decision Making: A Radio Interview”
• “I’m Dying to Know”
• “Can Good Care Produce Bad Health?”

Steve Jobs announces the availability of iTunes for PC computers in October, 2003. He was diagnosed with cancer the same month. (Justin Sullivan/Getty Images)

This post originally appeared on KQED’s NewsFix on October 7, 2011

Since Steve Jobs’ resignation as Apple CEO in August, many of the basic facts of his disease have been widely written about. Jobs had a rare form of pancreatic cancer, Pancreatic Neuroendocrine Tumors. The Wall Street Journal and The Washington Post both feature solid pieces with additional detail about this disease.

The American Cancer Society’s five-year survival rates for the more frequently diagnosed type of Pancreatic Cancer are bleak.  But for those afflicted with the rare type of this cancer Jobs had, survival rates are much higher.

For a moving obituary, the American Cancer Society’s Dr. Len Lichtenfeld had a surprising approach. He writes about Steve Jobs as a survivor.

 …his greatness is amplified by what he accomplished under the most difficult of circumstances. For here was a man who had an uncommon cancer that recurred and required a liver transplant. Here was a man who was failing in his health, yet had the fortitude to face every day as a new challenge, to do what he wanted to do, to accomplish successes that had never been accomplished before. Here was a man who embodied the drive and the spirit that so many cancer survivors possess every day of their lives, even when facing the ultimate moment as Steve Jobs faced today.

Here was a man living, really living, with cancer. But along with Jobs’ drive came a fabled stubborn streak. When his cancer was diagnosed in 2003, he initially refused the recommended surgery. Fortune magazine reported in 2008 that those closest to him were concerned.

 By the standards of medical science, it was an open-and-shut case: There was no serious alternative to surgery. ‘Surgery is the only treatment modality that can result in cure,’ Dr. Jeffrey Norton, chief of surgical oncology at Stanford, wrote in a 2006 medical journal article about this kind of pancreatic cancer.

On Wednesday, The Daily Beast built on the Fortune report in a lengthy critique of Jobs’ personal treatment decisions. In her post, Sharon Begley includes everything anyone would want to know about pancreatic neuroendocrine tumor, but also makes the case that Jobs’ insistence on directing his own treatment could have worsened his condition and perhaps even shortened his life. Again from the Fortune piece:

A Buddhist and vegetarian, the Apple CEO was skeptical of mainstream medicine. Jobs decided to employ alternative methods to treat his pancreatic cancer, hoping to avoid the operation through a special diet – a course of action that hasn’t been disclosed until now.

For nine months Jobs pursued this approach, as Apple’s board of directors and executive team secretly agonized over the situation – and whether the company needed to disclose anything about its CEO’s health to investors.

After the initial surgery, Jobs lived in apparent good health for several years, then in 2009 he received a liver transplant. Begley writes, “… removing the liver because it had become riddled with tumors that originated elsewhere [i.e. the pancreas] is rare. For one thing, liver metastases probably meant the cancer is elsewhere, too, such as in the bones or brain. Swapping out a cancer-ridden liver for a new one may therefore buy some time, but not much.” Begley further states the transplant itself could have been “counter-productive.” The regimen of immune-suppressing drugs needed to prevent rejection of a transplanted organ may hinder the body’s ability to fight the cancer.

We’ll never know if Jobs’ treatment decisions shortened, lengthened or had no effect on the length of his life. But we do know that he faced death squarely, as he outlined in his now widely circulating 2005 Stanford Commencement speech.

“Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. … Your time is limited. Don’t waste it living someone else’s life.”