Blessed by the Potato

All summer Blueberry has wanted to set up a lemonade stand. We finally got one set up this weekend.

Lots of lessons in setting up a stand. We didn’t get into the cost of goods sold or turning a profit — all the supplies were donated by us. A big one was about expectations: we did go through two pitchers of fresh-squeezed lemonade (~8 lemons), but did not have to worry about a queueing system for the mob. Lots of down time to contemplate being patient, and that our quiet suburban street only had so many potential customers to reach. However, almost everyone tipped her well above the 25 cents she was charging per cup, so she still walked away with a decent amount of money for her efforts.

Totally of her own volition, she choose to donate half the revenue to Answering TTP (which I matched to hit the minimum donation amount).

There were lessons for me, too: it was funny to see people making solid marketing suggestions, like putting colourful signs up around the neighbourhood to direct people to our sleepy street, and to watch as she just didn’t want to do that. And I could so see myself in that, and I don’t think I would have seen that as clearly if I didn’t see it mirrored in her. “Click-baity subject lines work, you’ll get more people opening your emails that way.” “No, I’ll only use descriptive, boring subjects!”

So I’m going to have to work on my marketing skills…

Anyway, I suspect this is not the last we have heard from our little entrepreneur.

My dad has read Atul Gawande’s Being Mortal, which discusses the suffering that people can experience near the end of their lives — particularly the suffering of medical treatments to extend those lives. There was no question about having surgery to remove his tumour — the cost-benefit there was huge (esp. as it had sent him to emerg). But he explicitly did not want to go through adjuvant chemotherapy, because chemo sucks and he knows that first hand, and he didn’t think it would have much in the way of benefits.

Then we met with the oncologist and found out that the regimen he’d have now would be much less severe than the kind of chemo he had a decade ago, and that the benefits were very real.

But exactly how to convey those benefits is a tricky matter. She told us, roughly speaking, that 50% of people with his kind of cancer would still be alive and cancer-free 5 years out — the surgery alone totally cured them, and taking chemo would be a pain in the rear but not actually help them because they were cured already. 20% of people would have had their disease come back, but not with chemo, while 30% would see their disease come back regardless of chemo. So, a 20 percentage point increase in chances, chemo sounded pretty good.

But it’s hard to frame that in a way that sticks. After hitting the first wall in chemo side effects, “20%” didn’t sound that great any more. So my dad wanted me to explain it to him plainly: he was giving up 6 months of his life (or at least quality of life) to chemo. What was he giving it up for? “How much longer will I live?” And I get it: he wants the benefit expressed in the same units as the cost, which would make decision-making so much easier. But the cancer stats just don’t seem to be expressed that way.

And it’s complicated: it’s not as simple as giving up 6 months, as there are probabilities and uncertainties there, like permanent adverse events, versus the probability of having a recurrence and dying (or having a much harsher round of treatment), or the probability of being cured of cancer for the rest of his life but then having a heart attack or stroke. Even if he was cancer free in 5 or 10 or 15 years, how much longer would he live otherwise? And giving up a year at 69 when he could go golf or enjoy the cottage is perhaps not worth gaining a year at 79 where he might not be having as much fun. These are all hard things to say.

Later, I found a chart that looked basically like this that helped show the survival benefit:

But even that is lacking, as when choosing whether or not to take chemo the percentage point increase may not be as important as the percentage increase. That is, if you’ve already got a 50% chance of survival, bumping that up to 70% is a 40% improvement in your situation — taking the chemo is better than the “20 percent” figure makes it sound.

So I made a pictograph, which I think may be a better framing for showing the benefit of chemo. The MSKCC nomogram has a similar display.

None of this really helps answer the question in the way my dad wants, with the benefit in the same units as the cost. I started to go down the road of maybe integrating under those survival curves, to try to quantify what the expected increase in lifespan was. I even went into some of the quality-adjusted life years research and found a set of results that I could use as a weighting function — after all, an extra month of good health at 69 is not quite the same as an extra month at 79 or 89. But I stopped because that’s guaranteed to be an exercise in false precision, and I’m not sure giving him what he wants there is the best way (and I’m also doubting myself because no one that I’ve seen in health science presents results in this way to patients — at most such things are used in health economics to talk about big picture costs and programs).

Following my dad’s surgery for the big C, the standard of care is to give 12 cycles of chemotherapy to kill any cancerous cells that may be out there and help prevent the cancer from spreading or coming back. He had chemo just over a decade ago, and it is not a fun time, so he was a bit apprehensive at the notion before meeting the medical oncologist. But the oncologist laid out the plan and the stats and he said that it made sense and agreed to do it.

About a week after his first cycle the worst of the effects were hitting him hard, and he was done. No more chemo, no thank you. Making life miserable now for a chance at some extra years when you’re like, 80, is a bad deal and why would he have ever agreed to do it?

I went over the next day, made some soup, he started to feel better, and we went through some literature together. He agreed that a declaration that chemo was over may have been hasty, and went back for his second cycle yesterday.

That chemo causes nausea surprises no one. This was a known trade-off going in, but once he was actually experiencing these highly unpleasant side effects he was ready to quit.

You don’t want to be rewriting your plan while your head is in the toilet. On top of just feeling awful, there may be some chemo brain that makes it extra hard to make a good long-term decision.

But even beyond chemo, that’s a generalizable lesson. We’ve seen it often enough in investing: the midst of a market crash is not the time to re-evaluate your risk tolerance — you were aware that there were risks to investing and accepted those risks when deciding on your asset allocation in the first place.

The story also underscores the need to write things down. And not just the result of the plan: we didn’t need to write down that he’d be going to chemo every other week for 12 weeks, we needed to write down how he came to that decision. That there would be nausea, and that it would be temporary, and it would be worth it because the survival stats said so. Because it’s while he’s feeling that moment of doubt and urge to quit that he needs to be reminded of why he’s putting himself through this.