COMMENTARY

How Would You Treat Your Spouse? Practical but Not Hard Evidence

H. Jack West, MD

Disclosures

November 16, 2022

What if the patient in front of you were your spouse?

It's an essential question to consider as a practicing oncologist, where the stakes of our decisions may be life and death and there often is no clear answer.

I was first asked this question — "What would you do for a member of your own family?" — as a medical student. But over decades of practice in oncology, I now often find myself asking it of myself.

I am particularly fond of putting myself in this mindset because it provides an opportunity to reflect on the range of reasonable treatment options and the pros and cons of each. And it underscores the essential truth that these decisions should be as personalized as the molecular profile of a cancer. Rather than presume that what is optimal for one person should be adopted for everyone, it offers an opportunity to review the priorities of the patient and reflect on what is most important for them.

Early in my career, I tended to present a series of options with a laundry list of their pros and cons and then asked patients how they would prefer to proceed. All too often, this open-ended question was met with "Umm…you're the doctor…you tell me."

However, after treatments for many hundreds of cancer patients, I now prefer to offer guidance in the face of many reasonable alternatives instead of a unilateral decision. And as with a molecular profile, not all answers are equally correct.

When a patient or caregiver asks me how I would treat my own family, the construct is collaborative and allows me to talk about decision-making on a plane that is different from discussing empiric evidence.

Physicians can quote chapter and verse on data demonstrating an improvement in efficacy endpoints or the toxicity profile in a broad population. But I have come to understand that most of my patients want the insight of what, based on my experience and interpretation of the data, I would recommend for them. Offering how I would approach the situation allows me to deliver my personal perspective while giving them explicit permission to adopt that view or not. "Shared decision-making" is a well-articulated goal in medicine, and "what would you do?" strengthens the therapeutic alliance.

That said, as much as I appreciate this strategy, it's important to recognize its limitations.

The answer to this question does not constitute concrete evidence to guide practice. For example, say that you test for molecular markers in a patient with resected stage II non–small cell lung cancer (NSCLC) and find a RET fusion. Do you adopt the premise established by the ADAURA trial of patients with resected stage II/IIIA EGFR mutation-positive NSCLC and give adjuvant osimertinib? Or recommend a RET inhibitor such as selpercatinib or pralsetinib, both approved in RET fusion–positive advanced NSCLC, even though we don't have data on them as adjuvant therapy for RET fusion–positive NSCLC?

While some might consider this a silly question because their interpretation seems completely obvious, there are others who are thinking the same thing about the opposite view. I have been in many multidisciplinary conferences (tumor boards, if you prefer) or debates at academic meetings in which we are weighing whether or how to extrapolate existing data to real-world scenarios just like this one.

In cases like this, the "what would you do if it were your spouse?" approach can serve as a tiebreaker to help get us off the bubble and follow a practical solution. But we shouldn't misuse this tool by presenting it as an evidence-based argument.

What do you think? Do you value — or perhaps dread — this approach in the clinic?

Like so much of what we do, there is plenty of room for debate.

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape. Dr West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.

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