The Conundrum of Remission

One of the basic tasks a medical oncologist must perform is to determine whether a patient's cancer has responded to treatment. This evaluation is usually made by measuring the size of a tumor on physical examination or x-rays, and if the lesion is at least half its previous size a partial remission is said to have occurred, which is an encouraging result. Even better, if the mass is gone then the remission is labeled as complete. Patients whose tumors shrink less than half, remain the same size, or increase in size are formally deemed nonresponders, and using this system of reckoning, thought to face a grim future. For many years formal clinical trials of chemotherapy reported repsonses in this objective manner, as a way to predict which patients have the best chance to extend their lives. Once a tumor is measured on an imaging study, the answer to the question "Did the treatment work?" must be communicated to the patient and family.

I am the doctor who walks into an examining room and delivers this news.

Obviously my job is easy if the report is reassuring, but what if the cancer has not responded to therapy? When an x-ray reveals a meager response, how does an oncologist share this information without delivering a crushing blow to the hopes of his patient? The truth is, the manner in which I counsel a patient is one of the little-known quirks of the field of cancer care. Depending upon my facial expression, my body language or my demeanor in general, my answer - even if it contains discouraging news - may still calm the anxious face in front of me. Like an actor I may choose the role I wish to play that day - rescuer or villain, optimist or cynic. I can attach my own personal slant to the interpretation of the x-rays that may cause the patient to vow to fight on, or simply give up.

On this day - strange but true - I am the ultimate spin doctor.

There is a problem, however, in using the response rate to predict survival. Many new treatments available in the battle against cancer, such as monoclonal antibodies or growth factor inhibitors, nicknamed targeted therapy, can aid a patient without significantly reducing the size of a tumor. Cancer growth can sometimes be arrested, leading to a noticeable improvement in the patient's symptoms. This outcome has been enthusiastically described as "turning cancer into a chronic disease". In this setting it matters less that the tumor has shrunk but that it is no longer growing out of control.

If a patient can actually co-exist with cancer, then the significance of the response on x-ray lessens. Now, living with cancer no longer becomes an all-or-nothing game, where only those who rid themselves of the disease completely have any chance for a future. Even if an x-ray shows no signs of remission, if a patient feels better after receiving treatment my job is to provide encouragement and hope.

The treatment of cancer is changing - from a game of pure chance to a game of skill - a long campaign, with many battles, retreats when necessary, and an ever-shifting strategy against a faceless enemy.

Cancer therapy is not like playing the lottery, won by only a handful. To me it is like a long run to the top of a mountain called Cure. Some patients travel only a short distance before they drop from exhaustion. Others can sprint for miles, barely visible to the eye as they climb upward into the furrows and ledges. Some even reach the summit. All who attempt this ascent, whether it ends close to the base or on the bright peak, deserve to be called the bravest of the brave.