What is the goal of treatment?

In the ideal world we want to cure everybody. But in today’s real world we cannot. So we have to define goals that can be realistically achieved.

I would have liked to hit tennis balls like Federer or Nadal, run marathons, sing like Beyonce, or dance like Michael Jackson, but sadly, I could not. I had to deal with the reality of my limitations. I could think, and interpret and integrate information and   knowledge, and take care of patients, so that is what I started to do 25 years ago. I had to define my goal.

Similarly, when we start a treatment plan, we need to tailor it to the goal:

 is cure in sight, or is it not?

Can we completely get rid of the disease and prevent it from returning? In that case, however harsh the treatment is, it is worth going through it. There is light at the end of the tunnel. Hang in there, we tell our patients, you’ll get through it.

If that is not possible, if the cancer has spread beyond cure, then we have to make sure that the treatment is not worse than the disease.

The goal is to make the person’s life better, or longer, hopefully both. That goal is called “ Palliative treatment”. This means that the Cancer is causing symptoms, like pain, cough, breathing difficulty, etc, and the treatment is meant to shrink the tumors and decrease the symptoms that they cause. Palliative treatment continues  for extended periods of time, and side effects of treatment add up. There is no end point in sight.

Which leads to the next question.

If the Cancer has spread, but is not causing any symptoms,

Is it necessary to treat?

Is there is any benefit to treating earlier than later?

 Would you live longer? Better quality of life?

If the answer to those questions is no, then the appropriate answer is to wait, watch and delay starting the treatment. That is not easy. It causes a lot of anxiety in patients and their families.

I had an elderly gentleman who used to come for his follow up appointments with his two grown daughters. His disease had spread into his lungs, but wasn’t causing him any problem. He was going to the gym, hanging out with his buddies, was in no pain and had a good appetite. What would we achieve by starting chemotherapy at this time? We had long discussions about the goal of treatment at each visit: he was happy, his daughters were anxious. Eventually as he started to develop a cough and breathing difficulty we needed to start chemotherapy. As he went through that, his daughters were happy we had waited. He had four good years while he was on “observation” alone.