Wednesday, February 02, 2005

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.


At 3:21 AM, Anonymous Anonymous said...

This post of yours hits home to me. I'm so glad that Oncologist like yourself and mine Dr.Dianne Miller know that cancer does not necessarly mean either there will be life or no more life. There can be a median, cancer as a chronic disease. I never realized this till it was presented to me. My doctor mentioned treating my cancer just like someone treats diabetes. The chemo helps keep my cancer in balance so that I am still able to do everyday things. I also believe that good quality of life is so important when considering chronic treatment. My chemo still allows for me to have that, in which makes a good mid point. So many people don't realize that there is life beyond cancer or even with cancer. I know many people out there think that once you have cancer that basically the end of the world, but I just want to let people know that I am living proof with many others friends of mine that life can coexhist with cancer. Most people that meet me on an everyday basis don't have a clue that I have cancer. Not all cancer patients are bald, pail and skinny. Thank you once again for your thoughts Dr.


22 Vancouver,BC

At 2:39 AM, Anonymous Anonymous said...

Thank you for such a wonderful post. I came across your blog recently and have enjoyed going through your thoughtful, well-written posts. You may not know this, but your blog address has been posted on the Johns Hopkins Ovarian Cancer board. There are many posters over there who have found your posts provocative, and some who have found solace in what you have written. I wanted to let you know this as I was the person who posted your address over on the JH board after discovering it through another survivor's page. I hope you don't find this an invasion of privacy (which you may, though this is rather public forum) and that you continue to post your insightful words. Thank you for all you have written. While the physician's need to humanize the patient is often acknowleged, the same is seldom expected from the patient. Your journal helps facilitate that exchange.

Thank you,

Alicia, dx grade 1, IIIa ovca, March 2003, age 22.

At 1:56 AM, Blogger Rudy said...

Thanks for this post, Dr. Craig. I came to your site from the Day By Day Cartoon. My four-year-old son, Samuel, has ALL leukemia with on "m" marker, so he's on an augmented ALL treatment protocol, doing well, in remission since August, following through on all the meds. At this moment I'm at City of Hope in Duarte, Calif., our place of treatment, on the 3rd floor pediatric wing, as my son just had a fever yesterday (I'm guessing as a side effect of Ara-C). Anyway, this is very helpful information. A blog about my son's treatment is here: - Rudy in Pasadena, Calif.

At 11:43 PM, Blogger Smallman said...

I skim a lot of blogs, and so far yours is in the Top 3 of my list of favorites. I'm going to dive in and try my hand at it, so wish me luck.

It'll be in a totally different area than yours (mine is about diabetes symptom) I know, it sounds strange, but it's like anything, once you learn more about it, it's pretty cool. It's mostly about diabetes symptom related articles and subjects.

At 9:48 AM, Blogger jon said...

I was looking at your posts about cancer stomach and found a good article about the same cancer stomach info too...

God luck with it : )

At 8:55 AM, Blogger thermoplastic resources said...

Looking for skin cancer picture information I came across this post. I totally agree with you and would feel the same way!


At 11:37 AM, Anonymous Anonymous said...

There are many so called alternative therapies for cancer symptom thyroid many of which I dont think actually do anything unless they are able to control the mind as well which has huge healing potential. I think most issues relating to cancer symptom thyroid can be accommofdated to some degree with these altenative therapies but I would not let it be my only treatement in the fight against cancer.

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