Guiding Patients Through Cancer Care With Compassion, Historical Perspective: Deborah Doroshow, MD, PhD

In part 1 of an interview with The American Journal of Managed Care^® (AJMC^®), Deborah Doroshow, MD, PhD, discussed her work guiding patients with cancer and their families and how that role evolves throughout different stages of the disease journey. She also reflected on how her PhD in the history of medicine informs the way she cares for patients today and what lessons from the past can teach us about modern cancer care.

Doroshow is an assistant professor of medicine at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai. She divides her time between the Early Phase Trials Unit, where she sees patients with a variety of solid tumors enrolled in phase 1 and 2 trials of novel agents, and the Center for Thoracic Oncology, where she treats those with lung cancer.

This transcript has been lightly edited for clarity.

You primarily work as a guide for patients with cancer and their families. What does this role look like in daily practice, and how do you ensure patients are informed without being overwhelmed about the future?

I take my role as a guide really seriously, and it is what I get up in the morning to do. I know, as both a family member of many people who have dealt with cancer and now as a doctor, how scary this process can be and how unfamiliar it can be, even if you are a doctor yourself or have experience in the medical community. I mean, just trying to deal with the medical system and keep track of your appointments is already overwhelming. Now, imagine having to deal with a life-threatening illness.

I really try to demystify things. I try to use very plain language without talking down to people; I don't think it's necessary to do that. But I always try to find out what folks know so that I can meet them where they're at. In terms of not overwhelming people, I'm really mindful that, especially at a first oncology visit, most people don't process at least half of what we talk about because they're so worried and upset about having a new cancer diagnosis. A lot of times, I set up a follow-up visit maybe a week after so that we can just readdress some of the same things again. Or, I'll assess where our patient is at and let them tell me, are they becoming overwhelmed? Is this too much information? I'll obviously try to suss that out myself and really tailor the interaction to where they're at on that day.

That means that for some patients, we talk about a lot of detail, and we might talk about different treatment options. Other patients want to talk about prognosis right away, but that's not what everybody needs. Sometimes it's best done over a series of appointments. Sometimes it's really important for certain family members to be there, and so we might have another visit with family members to really make sure we go through everything together. It's obviously not just a one-time visit; it's a continuing conversation and relationship that, in many cases, lasts a long time and that I really treasure.

How do you tailor your role as patients move through different stages of their cancer journey?

Having not had cancer myself, I cannot fully understand what it's like. I can certainly listen to what my patients [and] what my family members have told me about their experiences. Certainly, no matter what kind of cancer you're diagnosed with or how advanced it is, it could be a small lung cancer, [or] it could be the most terrifying thing that's ever happened to you in your life. It all depends on who you are, how you see the world, and how you understand your role in it.

I have patients who have very, very strong faith that gives them a lot of certainty, grounding, and support as they face the unknown. There are so many different people; there are so many kinds of patients as there are kinds of people, and I think part of my job is to really understand who my patients are as humans so that I can best and most effectively guide them.

Actually, when I first meet people, I tend to start by asking them to tell me about themselves as a human, and I don't mean as a cancer patient. I mean, where do they live? What do they do for fun? Do they work outside the home? Who are the family members they depend on the most? That kind of information is absolutely critical to making sure that I can help guide patients in the most helpful way possible.

How do you use your experience with history to help patients in the present? What can we learn from the past to better address the patients of today?

I am unusual in that I don't think there are any other oncologists who have a PhD in the history of medicine. There is a hematologist in Canada, but in terms of solid tumor oncologists, I think I'm it. As a historian, I study 20th-century American medicine, and it really helps me be a better doctor in a few different ways.

I think in terms of the history of drug development and how new treatments become available and are developed for people with cancer and other serious diseases, one thing that history gives me is humility. A lot of times, when there's a new possible treatment, you'll see it appear on the front page of The New York Times. Patients are calling me asking about it, it's on magazine covers, and people are very, very, very excited. Sometimes, you'll see statements in the media that you know the drug is really going to be transformative.

One thing that history gives me is a little bit of a grain of salt, because that has happened over and over again in the history of medicine, where we think a drug is going to be a miracle, a magic bullet, and it ends up being helpful for some population of patients but not for everybody and has some real downsides; we don't have any drugs that don't have side effects. I think it helps me temper my enthusiasm a little bit and be both optimistic—I’m a phase 1 drug developer, so I couldn't be a phase 1 doc if I weren’t optimistic—but also a little bit more reserved and a little bit more critical as different news comes out, especially as I help patients wade through media reports.

The other thing I think that we can really learn from history is how systematically different groups of people have essentially been denied the right to optimal health care, whether we're talking about people in terms of racial or ethnic groups, economic groups, rural groups, you name it. That's obviously a huge issue that we have today in terms of ensuring that all patients have access to the newest and most effective treatments. I do think about that a lot as I work with my patients on a daily basis.