If it is hard to comprehend the suffering that cancer patients go through because of treatment, understanding the ‘intent of treatment’ may help. The 2 intents of treatment are ‘cure’ and ‘palliation’.
The word cure is emotive. To patients, cure is the permanent removal of the cancer – never to come back. It is so powerful that doctors hesitate to use it – preferring ‘remission’ instead and preserving some ambiguity and uncertainty. Cure is achieved on looking back, after sufficient time has passed to rule out any chance of relapse. The chance of achieving cure depends on the type and stage of the cancer and the treatment(s) offered. Typically cure is achieved when a cancer is found early and removed by surgery. Sometimes cure is achieved with one treatment modality (even with chemotherapy such as for lymphoma). Other times, it is with a combination of modalities. For some cancers, colon cancer for example, adjuvant chemotherapy after surgery increases the number of people who do not relapse with cancer. The choice of treatments recommended depends on what the risk of relapse is and how much each option relatively reduces the risk. There is a constant urge to improve the result by trying different chemotherapies, combinations and lengths of treatment to get the maximum number of patients on the ‘cured’ side. Most patients would choose to have every possible thing done if cure is the goal. Patients would consent to take on significant side effects and sacrifices to time and quality of life if cure can be achieved even if the likelihood is small. The alternative would be to accept that the cancer is incurable.
The basis of the palliative intent is accepting that a cancer is incurable. The palliative intent has several objectives including the relief of symptoms (palliation), the increase in the total length of life (overall survival), the increase of time when the cancer is not growing (progression free survival) and the improvement of quality of life. Sometimes, patients achieve all the objectives – the oncologist’s ‘sweet spot’- when the treatment works while causing next to no side effects. Sometimes patients sacrifice one over another, for example a treatment that works but at the cost of moderate or severe side effects. Sometimes patients suffer severe side effects and find that their cancer is worse despite the treatment and probably would have been better off without it. An oncologist can make a good guess but can never definitely predict the actual situation beforehand. Because of the potentially competing objectives, it is crucial to know what is important to each individual and for them to be fully informed in the decision making process. It is incorrect to assume that an 88 year old has lived long enough and that a 44 year old primarily wishes to prolong survival. There is also physical reality – such as the patient’s wellness or performance status, organ function, the cancer’s pace of growth that limit time and options to try. These differences in objectives can also potentially cause friction between members of a multidisciplinary team in the interpretation of the worth and appropriateness of doing something.
Getting a patient to the sweet spot is a satisfying outcome. The patient is relieved from symptoms, the scans may show tumours shrinking and the trust that a patient has for the oncologist and the process deepens. Patients get their lives back, to enjoy, to work and to plan. As most treatment plans are imperfect, the result is often temporary. Also, the chance of success reduces in each subsequent line of treatment. Having experienced a good outcome before raises the patient’s expectations and possibly the oncologist’s stake in ongoing treatment. With each line of treatment the uncertainty about whether it works and whether it is tolerated is renewed. On a happier note, cure is occasionally achieved in the palliative setting. Some patients with metastatic disease may end up with no detectable disease after treatment and pass the time test. For example, some patients with metastatic colorectal cancer have remained in long term complete remission after surgery for the primary and liver metastases and chemotherapy.
The art of oncology involves the complex negotiation between hope and reality. The optimal treatment for a patient with cancer is a complicated decision to make: based on hard facts, such as the type and stage of cancer, patient characteristics and the treatments available and intangibles like what the patient wants to achieve, the time they have to do it and the toxicity that they are prepared to tolerate and can tolerate. The contexts of cure and palliation provide the philosophical framework to guide this.