Commentary: “The Lake Wobegon Effect, a Natural Human Tendency to Overestimate One’s Capabilities” (Wikipedia)

December 2013 | Thomas J. Smith

Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average. —Garrison Keillor

Having read the article by Wolf and Wolf in this issue of The Milbank Quarterly, the oncologist part of me asks, “Where’s the beef?” This is typical care: Mrs.Wolf, an eighty year-old former smoker but healthy woman, is found (serendipitously) to have a resectable lung cancer and is treated with a curative resection based on her physiological age rather than her chronological age, as suggested by most guidelines (Hurria 2013). Indeed, based on the evidence available when she was diagnosed (Henschke et al. 2006), screening is now recommended by the U.S. Preventive Health Services Task Force (Humphrey et al. 2013). Appropriately, Mrs. Wolf declined adjuvant chemotherapy, based on a somewhat informed choice. Then when her cancer recurred, she had a good response to chemotherapy, which lasted for at least four months. We have known for twenty years that compared with the best supportive care, chemotherapy gains the average person a few months of life and increases, from about 20 percent to about 50 percent, the chance of being alive one year later (ASCO 1997). The chemotherapy that Mrs.Wolf received, carboplatin and pemetrexed (Alimta R ), is as successful as any other (Incollingo 2013; Patel, Socinski, and Garon 2012), and she likely did not have any nausea or lose her hair. Her recurrence was treated with FDA-approved erlotinib (Tarceva R ) for second-line use in her type of lung cancer (NCI 2013). She got brain radiation and neck spine radiation, with fairly typical side effects. In addition, she was in the lucky 54 percent of cancer patients who actually used hospice and was with hospice for two months, many times the national average of eight days (Morden et al. 2012). She had a terrible last month with agitation, delirium, and increasing debility, which sounds like a nightmare, but cancer is a tough business, as is being eighty and having one’s brain filled with “mets” (i.e., metastases) and being radiated.

The full commentary is available below.

Author(s): Thomas J. Smith

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Volume 91, Issue 4 (pages 729–737)
DOI: 10.1111/1468-0009.12031
Published in 2013