The words we use in our communication with others, either verbally or in writing, may substantially affect the message being delivered. Of course, what is heard by the receiving party may not necessarily be identical to what we intend to convey. When one is dealing with the topic of cancer, its treatment and consequences, language that clinicians and members of the cancer research community use may have an even greater impact.
During 40 years of working in the oncology arena, I have witnessed the effects of certain words and terms commonly employed within the professional establishment whose unclear meaning and implications for patients, their families, and the general public may not have been adequately considered. Further, they may have resulted in unfortunate confusion rather than enlightenment. The following commentary highlights my perspective on several of these terms.
To palliate, “to make a disease or symptoms less severe or unpleasant without removing the cause” as defined in one English-language dictionary, is a critical goal of medicine, particularly for clinicians dealing with the manifestations of malignant disease. Critically, there is nothing in this definition that speaks to advanced, progressive, incurable, or end-stage illness. The term simply implies a specific therapeutic focus on directly controlling clinically meaningful symptoms, such as administering effective pain medications, rather than a more indirect effect resulting from the rapid or longer-term successful treatment of cancer. This could include, for example, alleviating abdominal pain from the reduction of peritoneal carcinomatosis in response to cytotoxic drug delivery. Although such strategies have become increasingly relevant in cancer management, the term palliative care or, more specifically, a clinical palliative care service, has become essentially synonymous to many patients and their families with end-of-life care. It is not uncommon for patients with cancer to initially decline the opportunity to benefit from the expertise of a first-class palliative care team simply because they assume that this focus on symptom management is inconsistent with the goal of maximizing efforts to prolong survival. As a result, a strong argument can be made to educate both the public and our own clinical colleagues that, although optimal palliation of symptoms is essential when providing end-of-life care, this specific focus and expertise has the potential to be beneficial to patients throughout their cancer journey.
COMPLEMENTARY ALTERNATIVE MEDICINE
It is difficult to identify a clinically related concept that is more inaccurate, distorted, misleading, and potentially dangerous than that of complementary and alternative medicine (CAM). Complementary, or the more appropriate term used today—integrative—clearly implies the use of a wide variety of approaches designed to optimize the quality of life and enhance symptom management during the course of standard antineoplastic therapy. These strategies range from spiritual and behavioural medical support to far less fully understood interventions, such as acupuncture. The critical point here is that there is nothing “alternative” about such interventions because in this model of care they simply do not substitute for known effective anticancer therapeutics. Lumping these completely different concepts together in the expression CAM delivers an inappropriate message regarding the medically legitimate goals of integrative oncology care. Take, for example, one rather bizarre report that appeared in a peer-reviewed journal several years ago. Investigators examined records in the National Cancer Database of 1,901,815 patients treated from January 1, 2004, through December 31, 2013, and identified individuals “who received complementary medicine,” as self-reported by 258 patients, or 0.01% of the total population in this database. The authors concluded that these patients were more likely to refuse conventional cancer treatment and experience inferior survival compared with those who did not list an interest in this approach to cancer care.1 In addition to the profoundly inadequate sample size for drawing any meaningful conclusions, the authors’ decision to consider individuals interested in alternative approaches to conventional therapy as being equivalent to those desiring an integrative strategy focused on enhancing the quality of life while undergoing state-of-the-art oncology care either unintentionally or intentionally distorts facts. The term CAM simply needs to be discarded, never again to be used by cancer specialists, other clinicians, or members of the research community.
PRECISION CANCER MEDICINE
As relevant as the term precision cancer medicine has become in describing a focus of modern anti-neoplastic drug delivery, there remains a serious issue with the way in which many in the oncology community are using it. Precision cancer medicine refers to a specific goal of our treatment paradigm: to become ever more precise in favourably impacting cancer-relevant molecular targets, measured by improved objective response rates, time to disease progression, or overall survival. The term does not refer to a specific time or event, such that one can declare treatment has achieved a state of being optimally “precise.” The fact that a particular trial of a theorized relevant drug-target combination has failed to reveal the benefits of that approach does not signify a failure of the process of precision cancer medicine. Rather, this outcome serves as an example of how the process should work, discarding approaches that have not demonstrated meaningful benefit while continuing to examine other novel strategies that will hopefully, following appropriate clinical investigation, achieve the desired goal.
There is probably a no more powerful word in all of oncology, and no potential question associated with more fear following the diagnosis of cancer, than when a patient or family member inquires: “Will I or my loved one be cured?” Of course, as all oncologists know, the answer to this question can be quite complex, depending on the tumour type, disease stage, and other considerations. The point here is that even when “cure” is a realistic—or at least not irrational—goal of therapy, achieving this clinical state, with important exceptions such as non-melanoma skin cancers, is something one only knows with reasonable medical certainty at some point in the future. Depending on the natural history of the specific malignancy in question, this may represent a period of many years into that future. Providing an honest but also encouraging and hopeful response is one of the first important challenges facing treating oncologists as they begin to assist patients through their cancer survivorship journey.