Success is not final and failure is not fatal.

Abstract

DOI: 10.1200/JCO.2014.55.2828 We cannot always anticipate how patients will respond to information we present them—even startlingly good news. Clinical oncology by its very nature is fraught with emotion and is full of uncertainty and ambiguity. Conveying uncertainty remains a major component of an oncologist’s clinical work. The fear, angst, and sometimes anger encountered with the development or progression of metastatic disease are common emotions in clinic. We are less familiar with the uncertainty and accompanying dilemmas presented by successful therapy in the metastatic setting. For the last 3 years, I have been treating Mrs P, a woman with multifocal metastatic disease. I have always been direct with her regarding the situation and have talked frankly about the fact that her sarcoma is not curable and treatment options limited. I am quite sure that she has no doubts about the palliative aims of treatment. On this particular day, she was due to see the nurse practitioner, so when I walked into the room, she sensed that it was because I had bad news. She is intelligent, sophisticated, and forthright and does not hesitate to articulate her opinions. On this busy clinic day, it was an all too familiar conversation regarding the development of recurrent disease, the uncertainties of trial participation, and the time commitment involved. For me, this was a wellrehearsed and easily delivered dialogue. Mrs P, who was also a master of communication skills, detected uncertainty in the nurse practitioner’s approach and recognized that my unexpected appearance signaled trouble. She treated the medical system with suspicion and at times with disdain. She expressed her thoughts about my treatment recommendation and the proposed clinical trial with candor and directness. In the end, she opted for the trial, despite the required effort and commitment. She did well. Months went by and restaging scans showed continued improvement. She tolerated the intravenous drug well. She and her husband were delighted. Her visits became routine and straightforward, the results consistently good. I would often quote my surgical colleague’s adage to her: “A quick visit is always a good visit.” On several occasions, she mentioned that she did “not want to be on this treatment forever.” I stuck to my narrative that, in this case, prolonged chronic therapy would be the best-case option for someone with her advanced stage of disease. After 1.5 years on therapy, restaging scans demonstrated a radiologic complete response. She tolerated the drug extremely well. So at this point, we began to discuss again the distance she had to travel to receive treatment and how long she ought to continue on the drug. Both the patient and her husband were getting tired of the journey and the uncertainty regarding the length of therapy. It was clear to all of us that she could not receive the investigational agent off trial. We had looked into that option with her, but there were almost insurmountable hurdles in getting this trial open (for a rare disease) at her local hospital. So Mrs P’s basic choice was to continue to travel to receive her maintenance therapy or stop. Her question remained: “How long must I continue?” Mrs P and her husband knew that stopping treatment would likely mean return of cancer. Although it was successful, we harbored no fantasy that therapy was curative, and it was this critical fact that she found unbearable. Her questions exposed other concerns, both financial and personal. From that point on, clinic visits became increasingly more challenging and testy. We would discuss the excellent scan results, continuing treatment or stopping, and then end the conversation by acknowledging the lack of data regarding outcome. We spoke of other patients who had continued on chronic therapy for metastatic disease with all the associated physical and emotional challenges of such protracted treatment. She appreciated the benefit she had obtained, and I would remind her that tragically other patients were not as fortunate. I could appreciate her concerns, the disease was uncurable, and she was essentially in limbo. Yes, the trial medication was good and she had derived clear benefit, but the choice was to continue with therapy indefinitely or stop. She was frustrated and derived no comfort from hearing other patients’ stories or any anecdotal evidence I could provide. More than 2 years after starting therapy, she returned with her husband for another routine scan. And once again, the scan showed a maintained radiologic complete response. I thought JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 30 OCTOBER 2