When I see a new patient with an advanced stage IV cancer, it is my practice to inform them, gently of course, that their tumor is incurable. I think it is necessary and appropriate that they should have an accurate and realistic view of their circumstances. And usually I know when a tumor is incurable. And I believe the term is an accurate description of their situation.
What about the converse? When can one tell a patient that they have been cured? In a paper published in JNCI Cancer Spectrum in 2020 by a team of investigators led by Benjamin Corn of Shaare Zedek Hospital in Jerusalem, the investigators analyzed the use of the term “cure” in over 13,000 articles that were published in two of the leading oncology journals, the Journal of Clinical Oncology and JAMA Oncology. They found that the term “cure” was used remarkably infrequently and, indeed, has been diminishing in use over time.
An accompanying editorial by two medical oncologists from the University of Sydney, Belinda Kiely and Martin Stockler, commented that these findings are especially odd in light of the fact that treatment advances in oncology are actually prolonging survival rates and reducing recurrences for many cancers as recent years have gone by. Thus, we should be witnessing increasing use of this term.
The truth is that the definition for the word “cure” in cancer does vary a bit. The American Society of Clinical Oncology (ASCO) defines a cure very simply as “when a person’s cancer has not returned for at least five years after treatment.” Another definition, from a study conducted in Italy, considered a person cured when the person’s expected mortality rate returned to the level expected in the general population of the same age and gender. This latter definition seems more appropriate, but would usually take significantly longer than five years to ascertain or determine. For example, hormone-receptor positive breast cancer, even if diagnosed and treated at an early stage, can recur and lead to mortality after 20 years or more. The same can be said of prostate cancer.
A survey was conducted among 117 American oncologists and published in 2013. The study reported that 81% hesitated to utilize the term “cure.” In fact, 63% stated that they would never use the term. For those who did use the term, they generally wanted six to 10 years to have elapsed before they were comfortable telling a patient they were cured. Only 36% of the oncologists stated that they would use the term for patients within five years of their treatment.
Cancer survivors live their lives in fear of recurrence. Use of the term “cure” to describe their status would be reassuring, comforting and reduce anxiety. Of course, it would come at the cost of having misled the patient if a recurrence does occur.
Some of the hesitancy in using the term comes from subtleties and nuances that vary from patient to patient and can affect prognosis. Thus, prognostication can be complicated and complex.
A more recent survey of 224 clinicians, including oncologists, surgeons and radiation oncologists, conducted in Italy, found that 90% would use the term “cure.” More than 80% of the respondents believed that use of the term would be beneficial to patients.
On the other hand, a recent survey of 229 adults who had survived a childhood cancer and were free of cancer for years reported that one-third had very significant anxiety and outright fear of a recurrence—who can blame them? Similar fears and attitudes have been documented in adult cancer survivors. The author of the study, Nicole Alberts of Concordia University in Montreal, suggested that such fears and concerns are normal and to be expected. She opined that while use of the word “cure” could possibly have some temporary benefits, the underlying anxiety and fears are appropriate and would resurface no matter what terminology were used.
Just to add my own thoughts on the question, we actually don’t cure most of the common diseases of middle and older ages—hypertension, depression, diabetes, coronary heart disease, lupus. We monitor and control them. But do people go up to endocrinologists in a similar fashion and inquire as to when we are going to cure diabetes already? Or to a rheumatologist as to the cure for lupus? I don’t know why a cure is, in many circumstances, more necessary in cancer than for the other diseases. The truth is that we do cure many if not most cancers and we control many more for extended periods.
I don’t think that most of my colleagues would dispute the fact that we routinely cure Hodgkin lymphoma, many of the non-Hodgkin lymphomas and leukemias, most pediatric cancers, testicular cancer and anal cancer. We also cure most early-stage solid tumors that are amenable to resection—breast cancer, colorectal cancer, melanoma, prostate cancer, even non-small cell lung cancer. If we do not use the word “cure” in these contexts, when do we use it?
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
