I clearly remember that one of one of the first lessons I learned as a resident doctor managing cancer patients in the ward was the curative versus palliative dichotomy. We had to go hard and stop at nothing for those patients in the curative group. But in the palliative group, how far we pushed was much more arbitrary. That was in the early 2000s.
Cancer treatment landscape has rapidly and significantly advanced since then. But our binary language around treatment intent hasn’t quite caught up with these radical changes.
Drastic changes in treatments has happened not only in systemic therapies such as chemotherapy, biological therapies, and immunotherapies, but there have been significant advances in radiotherapy techniques and surgery pushing the boundaries leading to better outcomes. As a result, a scenario that was clearly non-curable a decade ago is now transformed into curable or potentially curable scenarios. Many examples exist across the spectrum of cancers from melanoma to lung and colorectal cancers.
A stumbling block, to embrace and move with these advances, is these definitions inherited from a bygone era where effective cancer treatment was a limited proposition. Those circumstances resulted in a dichotomy – there was a minority of patients who could be cured, defined as curable, and the remainder were defined as palliative. As a result, the treatment intents, often set at the time of diagnosis, dichotomised to “curative” or “palliative”. These definitions embedded themselves into oncology vocabulary and clinical trial design. Yesterday’s clinical trial data is the dominant data source for today’s decision making. Therefore, not only are we hamstrung in communicating ideas, but the data source to back those ideas are also tainted by old definitions, thwarting progress in cancer.
In my practice, I see curative versus palliative intent as two extremes of a spectrum that is no longer useful for any conversation with the patient. Palliative, the word itself, has negative connotations for the doctors and broader public, and it’s not a helpful way to start a conversation about treatment intent.
I’ve adopted a more broader proposition in this spectrum. I prefer treatment intent being “radical” or “non-radical”. I acknowledge that this needs some explanation. Radical intent can be defined as treatments aimed at achieving a substantial remission or cure in a given set of circumstances. I define treatments as all available therapies, not just chemotherapy, and may include biological therapies, surgery, radiotherapy, and other locally ablative techniques.
On the other hand, non-radical treatment is reserved for patients who are unlikely to be able to tolerate those treatments that are relevant to the other group. This is due to a variety of underlying factors such as their pre-existing medical illnesses for example. In this situation, the intent is to prolong life while prioritising quality of life versus quantity.
I also view the intent as something that is reviewed and revised at each step as we navigate through the treatment landscape. I find this approach leaves us open to all possibilities in the spectrum. For example, a patient having non-radical treatment might have an exceptional response that could then make radical interventions feasible. On the other hand, a patient starting with radical intent treatment might develop serious complication, which then precludes pursuit of that pathway and, at least for a period of time, requires us to revert to a non-radical approach.
I find it provides me with the agility and openness to have frank and honest conversation with the patients.