NN&I - May 2010
Viewpoint 14 Nephrology News & Issues May 2010www.nephronline.com At the Medicare Evidence Development and Coverage Advisory Committee (MedCAC) meeting held on March 24, new concerns about ESA dosing were aired after recent clinical trials sug -gested high doses, high hemoglobins, or both, might be dangerous.Drug safety is important. But we shouldn't lose sight of the positive value ESAs have brought to patients. Why are people with CKD who take ESAs less worthy than those with other health problems to make their own trade-offs between quality of life and survival? Think about these examples in other areas of health care:A study of men with prostate can- \037 cer found that all participants pre-ferred to die sooner rather than use a long-term androgen deprivation treat -ment that would have made them per -manently impotent.1 Women with recurrent ovarian can - \037 cer overwhelmingly preferred salvage therapy to save their livesregardless of quality.2People with heart failure varied in \037 their preferences for survival vs. quality of life; about 60% were strongly polar -ized toward one or the other.3 Individuals with ulcerative colitis \037 nearly all refused to consider elective colectomy to reduce their 20% risk of colon cancer. On average, they would only agree when the risk level "right now" increased to 73%.4Each of these studies focused on patient preferences, and respected patients' investment in their own lives Quality vs. quantity of life with ESAs: Only patients should decideDori Schatell, MS Ms. Schatell is the executive director of the Medical Education Institute, based in Madison, Wisc. MEI's evidence-based professional and patient education efforts focus on helping people live long and live well with kidney disease, and home dialysis of all types.and ability to make an informed choice when presented with accurate informa -tion about treatment options. Where are the patient preference studies on ESA tradeoffs in CKD? In our own research, actually inter -viewing 29 people with CKD about their experience of anemia symptoms, we heard heartbreaking stories like this one:"Everything that I do is such an effort that I can't possibly do it. Even walking from the bedroom to the kitchen, I rest after every two or three steps. I stop, because I don't have the strength to walk with. My quality of life has dropped so much that it's almost unbearable. I'm not able to do any -thing to help my wife." A reanalysis of our data identified that patients associated anemia with decreased energy (79%), feeling tired (76%), shortness of breath (72%) and loss of strength (66%).6 As part of its review, MEDCAC is interested in whether there is "sufficient evidence" that anemia treatment per seand ESAs specificallyaffect exer -cise tolerance, vascular events, patient- perceived quality of life, and survival. There are reams of studies, but what really matters to each individual patient is the ability to choose for him or herself whether a) to feel better on a day-to-day basis in the short run, while possibly facing a higher risk of an earlier death, or b) whether to maximize survival at the cost of quality of life. Interestingly, we don't seem to have any difficulty allowing patients to choose to end their lives on dialy-sis. Per the United States Renal Data System 2009 Annual Data Report, of the 214,289 patients who died on dialy-sis between 2004 and 2006 (21.5% of all patients), 23% withdrew from dialy-sis. A small percentage stopped treat -ment due to access or transplant fail -ure, while nearly half "failed to thrive." Some were likely depressed (this is rarely assessed), and some perhaps just didn't consider their quality of lives worth continuing. We don't really know why. But does it make sense to allow people to choose to diebut not to live better? References1. Wilke DR, Krahn M, Tomlinson G, Bezjak A, Rutledge R, Warde P. Sex or survival: short-term ver -sus long-term androgen deprivation in patients with locally advanced prostate cancer treated with radio-therapy. Cancer. 2010, Feb (ePub ahead of print) 2. Donovan KA, Greene PG, Shuster JL, Partridge EE, Tucker DC. Treatment preferences in recur -rent ovarian cancer. Gynecol Oncol. 2002 Aug; 86(2):200-113. Lewis EF, Johnson PA, Johnson W, Collins C, Stevenson LW. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant. 2001 Sep;20(9):1016-244. Siegal CA, Schwartz LM, Woloshin S, Cole EB, Rubin DT, Vay T, Baars J, Sands BE. When should ulcerative colitis patients undergo colectomy for dysplasia? Mismatch between patient preferences and physician recommendations. Inflamm Bowel Dis. 2010 Feb 23 [Epub ahead of print] 5. Schatell D, Witten B. Anemia: dialysis patients' experiences. Nephrol News Issues. 2004 Nov; 18(12):49-54 6. Lasch KF, Evans CJ, Schatell D. A qualitative analysis of patient-reported symptoms of anemia. Nephrol Nurs J. 2009 Nov-Dec;36(6):621-4, 631-2; quiz 633Viewpoint Viewpoint_NNI0510_5.indd 14 4/16/10 1:53:17 PM
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