In the previous section on the advanced stage of disease (THERE’S A TUMOR AND THINGS AREN’T GOING WELL) there appears to be a blatant contradiction; on the one hand, we say that the disease is no longer curable; while on the other, we say that a patient with a local recurrence has a better chance of being cured than one who has distant metastases. Moreover, even if there are metastases, exceptional cases may be seen. So then, can a patient with advanced cancer be cured or not? This issue needs to be clarified, as it is often a source of misunderstanding.
It is all a question of probability. Generally speaking, the chances of curing advanced cancer are well below 10%, around 5% on average. Moreover, there are great differences between one tumor and another: in pancreatic cancer, for example, the chances are below 1%, while in the case of breast cancer, they are above 10%; a probability of 1 in 10 is very low, but a 1 in 100 chance is almost no chance.
This makes it difficult to communicate the true possibility of cure. Doctors do not want to arouse false hopes, and they know that the human mind tends to overestimate low probabilities; if they say that there is a 1% chance of cure, the patient is likely to twist this into a more acceptable “they say I can be cured”. By contrast, if a patient in an advanced stage of disease has a much better chance, though still low (5-10%), the doctor will generally express this hope.
We can simplify the complexity of this issue by distinguishing conditions that leave some room for hope from those in which the hope of cure is close to 0.
Situations in which there is still room for hope concern:
- patients with local recurrences that can be eliminated by means of surgery in combination with radiotherapy and medical therapies;
- who have 1-2 distant metastases with features that allow us to hope that they can be completely eliminated and will not form again elsewhere;
- patients with metastases in many organs, but who respond so well to medical therapies that the tumor shrinks and finally disappears (COMPLETE RESPONSE). This last condition may result in cure, though this is rare; unfortunately, the majority of these patients will relapse again.
Less favorable conditions, in order of increasing gravity, regard:
- patients with scattered metastases who have not responded to first-line medical therapy (therapy administered as the first choice);
- with scattered metastases who have already failed to respond to the therapies administered after the first therapy (so-called second-line, third-line and beyond). Clearly, the situation of this second group of patients is much more serious than that of the first group, and the hope that keeps them going forward through their second-, third- or fourth-line therapy is that “in the end, they’ll find something that works and gets rid of this tumor” and that the future will be brighter.
- patients who can no longer undergo anti-tumor therapies, but only supportive therapies. There comes a time when we are no longer sure whether anti-tumor therapies should be continued or not. On the one hand, carrying on with toxic treatments that are only of minimal efficacy can be seen as a kind of “stubbornness”. On the other, discontinuing anti-cancer drugs because they cause harm and seem to be useless, when in reality they may still be able to offer “something”, can be seen as a sort of abandonment. The middle way between stubbornness and abandonment is very narrow and difficult for all concerned: doctors, patients and their loved ones. However, even when the decision to discontinue treatment has been taken, this does not mean abandoning the patient; it is still possible to help by administering supportive therapies, i.e. nutritional support and treatments to alleviate the pain and the typical symptoms of advanced cancer.