Article - Winter 2022

Never Take Hope From the Patient

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Sometimes the best treatment includes a healthy dose of optimism, even when it’s not warranted

By Patrick Tripp | December 1, 2021
Raymond Forbes Photography/Stocksy
Raymond Forbes Photography/Stocksy

In City of God, Saint Augustine tells the story of Innocentia of Carthage. Diagnosed with breast cancer, she was advised by a physician to follow the ancient recommendation of Hippocrates: “It is better and safer not to treat than to treat a hidden cancer : let a good diet be sufficient.” Later, in a dream, she was instructed to go to a church and ask a newly baptized stranger to make the sign of the cross on her breast. Upon waking, Innocentia did just that and was cured. Medicine derived from dreams and miracles continued at least until the 14th century, when French physician Jean de Tournemire, whose 18-year-old daughter was afflicted with breast cancer, prayed for intercession from Avignon cardinal Peter of Luxembourg. De Tournemire had diagnosed his daughter himself, palpating a nodule the size of a hazelnut with corrosio fortis, or the rough, ulcerated fissures that he recognized as the “unmistakable” signs of an advanced cancer. A colleague recommended surgery, only with “great fear and caution, after the surgeon is persuaded by many insistent requests and a very high fee.” Application of curative ointments, or insufficient surgery, might only expedite ulceration of the tumor, hastening death. De Tournemire, too, recalled Hippocrates’s aphorism. His daughter didn’t need an operation; she needed a miracle.

A 74-year-old man with metastatic lung cancer, Mr. R, was referred to radiation oncology for possible treatment for an asymptomatic tumor in his chest. A surveillance scan showed that the primary tumor,  in the right lower lobe of his lung, was growing, while the few metastatic sites he was living with, in his sacrum and liver, appeared to remain controlled by the chemotherapy he’d been on for 10 months—about two months longer than the median survival for metastatic lung cancer.

At first, it was not clear why he’d even been referred to radiation oncology. As a rule, patients with metastatic cancer cannot be cured. Chemotherapy can add months, which is why it’s usually recommended, but radiation is generally used only to manage a specific problem, such as pain, bleeding, an obstructed airway, or neurological changes from spinal cord or brain metastases. Mr. R did not have any of these problems. The indication for radiation, said his medical oncologist, Dr. Charles, was merely to go after the growing tumor in his chest, a problem neither patient nor doctor would have known about but for frequent surveillance scans to assess Mr. R’s response to chemotherapy. Systemic treatments for metastatic cancer, like chemotherapy, offer diminishing returns—the chance of seeing a durable response, or any response at all, declines with each additional cycle of treatment. Moreover, once patients stop benefiting from the first approach, the odds they’ll see improvement from other lines of treatment dramatically decrease.

In the 1990s, the term oligometastatic was introduced to describe a subcategory of patients with metastatic cancer who may respond more favorably to treatment. Institutional series and case reports focused attention on patients with oligometastases (from the Greek “few” or “scanty,” describing a limited number of metastatic sites) who, after receiving surgery or radiation on those sites, appeared to live longer compared with patients treated with chemotherapy alone. These reports suggested a different way of looking at metastatic cancer: its spread was not an all-or-nothing phenomenon with malignant seeds exploding simultaneously throughout the body; instead, one metastasis evolved the capacity to seed an additional one, or several, in sequence. By this hypothesis, it made sense to treat the first few visible sites and, by extension, to treat even the primary tumor site with curative intent—in effect, to approach a metastatic patient with the same intensity of treatment as if the patient didn’t have metastases. Still, no medical intervention is without risk: sometimes, as de Tournemire’s colleague warned, more aggressive treatment can end up doing more harm than good. I called Dr. Charles to ask whether this approach was what he intended—to treat a metastatic patient using curative radiation chemotherapy to the chest, with all its harms and risks, even though the chances for cure were almost zero.

“That’s right,” he said. Dr. Charles had earned a reputation—and gained a measure of fame—for continuing to treat lung cancer patients long after they had any hope of survival. He did not sit down with patients to inquire about their beliefs and values. He knew that they sought him out not for his bedside manner but for his willingness to do everything possible to extend their lives, even if that meant sending them to me for risky radiation treatment that carried uncertain benefits. When I tried to raise my concerns with Dr. Charles, he cut me off. “It’s not investigational!” he said.

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