When Chemotherapy Doesn’t Palliate

I had taken care of her for many years: recommended the adjuvant treatment for her triple-negative breast cancer, then later, walking her through treatment when we found it had recurred in her liver. We had hoped for a long-lasting remission, but then she developed bone and lung metastases.

We reviewed how metastatic cancer can be viewed as a “chronic disease,” not as a “curable” one. She was devastated and scared, but came to accept “cancer can be as diabetes” as her mantra. We opted for further treatment and talked about achievable goals of therapy: disease control and the treatment of cancer-related symptoms (and in the absence of them, to prevent any that might occur).

Third-line chemotherapy provided that control, but unlike her prior experiences with treatment, it came with a cost. She lost her hair again and for the first time, had trouble eating due to mouth sores and persistent, unrelenting nausea. She was determined to live her life and did not let any of this stop her from her full-time job and being mother and wife. Due to her nausea I recommended we dose-reduce her chemotherapy, to which she replied, “Why would we do that if it’s working?” I still remember wanting to review the dual goals of treatment—control of disease and of symptoms—but instead, I acquiesced sensing she was singularly focused on “disease control.” “OK then. We will continue.”

She stayed on treatment until it ceased working, and we talked about our next steps. She seemed relieved that this regimen had run its course—the side effects were getting harder and harder to live with. She admitted to me that she had scaled back on work and that friends had stepped in to help her at home. When we reviewed the next few options, I had hoped to see the same engaged patient sitting there with me, helping me decide. Instead, I saw tears in her eyes as she admitted, “Can I do this? Honestly, I don’t know if I can take much more. The treatments are worse than any cancer side effects I’ve yet to experience.”

Her concerns jarred me a bit. I had expected her to do as she had always done—choose among the options presented and do so readily. As I looked at her now, I saw that living with cancer is hard; that beyond the philosophical discussions on “lives worth living” and how one can “live with cancer,” at some point, that living can make the strongest person feel weak.

I reached out to Dr. Eduardo Bruera for his thoughts on my patient. In addition to being a member of The Oncologist’s Editorial Board, Eduardo is Professor and Chairman of the Department of Palliative Care and Rehabilitation Medicine in the Division of Cancer Medicine at The University of Texas MD Anderson Cancer Center and participates actively as part of the Advisory Group on Supportive Care Guidelines for the American Society of Clinical Oncology.

You and your patient show how important communication is, particularly around the notion of "palliative" cancer treatment. It’s important that we remember to ask our patients how they feel about their situation, about therapeutic choices. In your case, the relationship you developed with her over time allowed her to feel safe, and she brought up her concerns about more treatment. Many patients may not feel that safe, and may not even know the option for "no treatment" is a fair one. It’s as important that as oncologists we offer "no treatment" as a fair alternative, and that we believe this to be true. I think patients may see reassurance in such a stance—especially if they harbor a sense that to not go forward with more treatment, they risk the "disappointment" of their doctor.

At the time I had met with my patient, I realized clearly my role in our doctor-patient relationship and perhaps, my biases within it. I had to admit that each conversation on treatment options had been highlighted by the chances of a tumor response or tumor stability with less focus on the toxicity and side effects. I recognized how some visits emphasized the assessment of the tumor’s response to treatment rather than quality of life. Why this would be was simple—I wanted her—and all of my patients—to do “well.” I wanted this particular patient with metastatic breast cancer to be the rare patient who achieves remission even with later-line therapy, and short of that, to experience prolonged disease control with no cancer-related symptoms—no pain, no jaundice, no fatigue. I needed to believe that this was possible—because I want her to live.

To this, Eduardo responded:

The drive of oncologists to want their patients to do well is so important; it is the concept of wellbeing, but in this context, the goal of the oncologist can be to help our patients be well—even when they do not "do well" from the perspective of cancer treatment and their response (or lack of one).

As oncologists, we strive to be clear with the intentions of our treatment. Adjuvant therapy when the goal is cure or remission and then, medical treatment administered with non-curative intent. But women like my patient present a clinical dilemma for me. What if someone recurs but is asymptomatic? What is the role of chemotherapy when there is nothing to palliate, especially when we can no longer cure?

Ultimately, I realize I need to be cognizant about my own objectives and hopes for her, and for each patient. So for this one woman, I took a step back and questioned, “What are we doing?” because if I wanted to really help, I would need to look at the person with the cancer, not just the cancer within the patient.

Eduardo concluded by reminding me (and us) of the importance of continuous reassessment of the patient’s views, especially when the goals of cancer treatment are far from cure.

Patient-reported outcomes tools such as the Edmonton Symptom Assessment System are important. It takes less than two minutes, is completed by the patient in the waiting room, and it is free to use. Most importantly, it will let us know how they are doing—as persons—in addition to the information we routinely collect on treatment side effects, tumor responses, and medical comorbidities.

For this patient, we opted to stop treatment, at least for a while. She wanted to use that time to recover from therapy’s side effects and to resume her life as mother, professional, and wife. After we talked, I realized too, I owed her that much.