Originally published in "Discussions with Don S. Dizon" on The Oncologist
I remember, when I was a kid, that my grandmother would spend time at our breakfast table reading the newspaper. Not cover to cover, mind you—she seemed to always focus her attention on the obituaries. Sometimes she would look up and tell anyone sitting around her about the death of someone near her age or, sometimes, someone very young. It was the first time I remember hearing how someone “lost the fight to cancer.” It is something I have heard many times since, and it continues to bother me. I’ve written before how the war analogy implies winners and losers, but even more than that, the analogy assumes only two outcomes: remission or death. No middle ground. And today more than ever, nothing is further from reality.
Such was the case with Mary*. She had seen me for a second opinion for recurrent ovarian cancer. She had been diagnosed 3 years previously, and following curative-intended surgery and chemotherapy, went in to remission that lasted a little over a year. Since then, she had been living with recurrent disease, and when she saw me, her treatment (third regimen) had stopped working. Her cancer had progressed by CAT scan and by CA-125.
She was despondent when we spoke, near tears. She wanted to be “rid of” the cancer, needed to be in remission, and was willing to do anything for it. “I don’t care what I have to do, Doc,” she told me. “I just want to be cancer free.”
I remember sitting back and letting her talk about her focus on remission, the “fight” for cure. Yet, sitting before me was a woman who did not look sick. She had a full head of hair, wore makeup, walked in independently. She had no bowel or bladder issues, was eating normally, and was still able to work full-time. Suffice to say, she looked very much alive.
“Can I ask you something?” I asked.
“Sure,” she replied.
“Why are you fighting for cure?” I asked her. “I mean, you’ve been dealing with recurrent disease for the better part of 2 years, and the treatments you’ve been given have worked, at least for awhile. I’d say you’re very much alive despite this disease, wouldn’t you?”
“Well,” she started. “If I have this cancer, then I am going to die of it, and I don’t want to die.”
It was then that I realized that she was confronting her cancer as black and white: remission or death.
“Mary, it might’ve been that before we had many more choices, patients who relapsed did die of their disease, and did so within a matter of months. While that still happens, it is far from the norm, and as you are proving, it is quite possible to experience a third alternative: living with disease,” I said. She sat up then, as if hearing this for the very first time.
“I feel that for my patients with recurrent ovarian cancer, my job is to try my best—to treat cancer to the best response possible and with as little toxicity to my patient. For those whose disease has recurred a couple of times, I know remission is pretty unlikely, so I try to pick treatments that can keep the cancer is check—to get it dormant, so that it’s no longer growing. If I can do that, and do it without making someone feel sick, it’s a good thing.”
She didn’t talk while I spoke, but at the end she said, “I don’t think I ever considered that option—to be alive with disease. They say cancer is a fight, and I wanted to win. This disease is so awful, I just want to win.”
“Mary, cancer isn’t a war. It’s a disease and, with new developments, it’s one we can control. There are no winners or losers in this. There is a woman, with a disease, who wants to live in spite of it. This is where I can help. No, I cannot cure you, but I can help you control it.”
She did something then that surprised me: she smiled. “Thinking about it this way makes it so much easier for me. I had so much anxiety about the cancer not being in remission, and what you’ve said presents an entirely different way of thinking about it. I actually see light in this very dark tunnel.”
With that, we made arrangements to start a new treatment, one that would be tolerable with a good probability that the cancer would not grow.
Ultimately, Mary showed me that the power in medicine may not lie in our ability to find the next best treatment. It might be in helping our patients confront their own realities. For some, it will be to help them manage side effects from curative-intent treatment, while for others, it will be to help them confront the end of their own lives. But for so many of our own patients, like Mary, it will be to help them mentally adjust to a new reality of living with cancer as a chronic disease. The fact that this is a real option now is a testament to how far we’ve come.
So, let’s stop calling cancer a war. It’s a disease, and one that many can (and already do) live with.
*Name and identifying details changed for patient privacy.