Taking “Aggressive” out of treating cancer

Ralph - Seattle, Washington
Entered on May 22, 2008

I aggressively fight cancer, but I don’t say that to my patients.

Physicians are trained not just to treat diseases, but PEOPLE with diseases. I am a resident training to be a radiation oncologist. My patients have cancers, most of which can shorten their lives and can cause physical, mental, and social distress. Patients come to my clinic looking for not just cures, but relief and hope.

After reviewing my patients records and imaging, meeting them and discussing their understandings of their diseases, and sometimes obtaining new studies, my senior doctor and I offer treatment options including recommendations. Patients rely on those recommendations. Oncologists use adjectives, and “aggressive” is one frequently uttered. I don’t like that. I think it is a loaded term.

“Aggressive” in our health care system means “going all out” against the cancer: often including surgery, radiation and chemotherapy. It offers the best chance of good statistical outcomes: more time until the tumor comes back, better ability to keep the tumor from growing, and sometimes a longer life. These statistical endpoints are not without costs: side effects of therapy, consumption of many days, weeks, and sometimes months in hospitals receiving therapies and recovering from them, and financial costs.

In some instances, choosing the “aggressive” option is starkly the right decision. In other cases, it is less clear. The “golden ring” for which patients and their doctors are reaching can be far from reach; sometimes the best randomized studies show the new, more aggressive treatment regimen offers no better than a one in ten chance of an improved outcome compared to conventional therapy with less side effects. Conversely, rarely do we use the term “aggressive” to describe how our health care system will approach providing comfort and support to someone’s disease. Like soldiers returning at war, we honor patients who bravely fight and beat their cancer. Those who succumb to their disease are remembered fondly for the strong fight in which they suffered.

It is in this context that I refrain from using the term “aggressive” as I describe treatment options. It may be meant as a descriptive term; but in our culture, it is also a selling point—whether intended as such or not. In this environment, being “aggressive” is right for many patients, but not all. It takes a remarkable person, particularly in the setting of family members, to reject the aggressive option.

I believe in patients’ abilities to make the decisions that are best for them, if given information dispassionately. The “aggressive” option is often the one I recommend, even if I don’t call it that. I hope I am equally supportive, regardless of my patients’ decisions.

By not using one word, in some small way I hope to allow patients make better decisions for their lives. Omitting one word does not completely change the context in which my patients’ cancer care decision are made; nor does it change the other biases with which I approach health care. But it is a start.