Never Take Hope From the Patient
IN CITY OF GOD, Saint Augustine tells the story of Innocentia of Carthage. Diagnosed with breast cancer, she was advised by a physician to follow the ancient recommendation of Hippocrates: “It is better and safer not to treat than to treat a hidden cancer›: let a good diet be sufficient.” Later, in a dream, she was instructed to go to a church and ask a newly baptized stranger to make the sign of the cross on her breast. Upon waking, Innocentia did just that and was cured. Medicine derived from dreams and miracles continued at least until the 14th century, when French physician Jean de Tournemire, whose 18-year-old daughter was afflicted with breast cancer, prayed for intercession from Avignon cardinal Peter of Luxembourg. De Tournemire had diagnosed his daughter himself, palpating a nodule the size of a hazelnut with corrosio fortis, or the rough, ulcerated fissures that he recognized as the “unmistakable” signs of an advanced cancer. A colleague recommended surgery, only with “great fear and caution, after the surgeon is persuaded by many insistent requests and a very high fee.” Application of curative ointments, or insufficient surgery, might only expedite ulceration of the tumor, hastening death. De Tournemire, too, recalled Hippocrates’s aphorism. His daughter didn’t need an operation; she needed a miracle.
A 74-YEAR-OLD MAN with metastatic lung cancer, Mr. R, was referred to radiation oncology for possible treatment for an asymptomatic tumor in his chest. A surveillance scan showed that the primary tumor, in the right lower lobe of his lung, was growing, while the few metastatic sites he was living with, in his sacrum and liver, appeared to remain controlled by the chemotherapy he’d been on for 10 months—about two months longer than the median survival for metastatic lung cancer.
At first, it was not clear why he’d even been referred to radiation oncology. As a rule, patients with metastatic cancer cannot be cured. Chemotherapy can add months, which is why it’s usually recommended, but radiation is generally used only to manage a specific problem, such as pain, bleeding, an obstructed airway, or neurological changes from spinal cord or brain metastases. Mr. R did not have any of these problems. The indication for radiation, said his medical oncologist, Dr. Charles, was merely to go after the growing tumor in his chest, a problem neither patient nor doctor would have known about but for frequent surveillance scans to assess Mr. R’s response to chemotherapy. Systemic treatments for metastatic cancer, like chemotherapy, offer diminishing returns—the chance of seeing a durable response, or any response at all, declines with each additional cycle of treatment. Moreover, once patients stop benefiting from the first approach, the odds they’ll see improvement from other lines of treatment dramatically decrease.
In the 1990s, the term was introduced to describe a subcategory of patients with metastatic cancer who may respond more favorably to treatment. Institutional series and case reports
