Doctors frequently rely on metaphors to communicate complicated and technical biological concepts to patients. For cancer treatment, the metaphor of a battle or war has been used at least as far back as 1971, when then President Richard Nixon famously declared war on cancer. Indeed, some of the early treatments for cancer were noxious poisons developed for chemical warfare. The war mentality was useful when a clinician was trying to convince a patient to accept the risks associated with these early forms of chemotherapy. But like military weapons, the tools we use to target cancer have become more precise and strategic, and they lead to higher response rates, greater disease control, and longer survival. We are certainly curing the disease of some patients today who in years past would have died of cancer. We have made even greater progress in extending the time that patients live with advanced cancer—well beyond historical prognostic expectations. If treating cancer is a war, it feels more like a stalemate than an existential threat. So, how do we define winning in this current context? I’ll share two patient experiences that show how winning can have more than one definition.
Dominic was determined from the onset to “beat” his cancer, no matter what it took. He chose a radical prostatectomy and subsequent radiation therapy for localized prostate cancer; when these approaches failed, he crisscrossed the country seeking out specialists. Even though he lived in North Carolina, he didn’t land on my doorstep until well into his cancer journey. After his disease progressed despite the use of several new and emerging therapies, it was clear to me that he was dying. I remember a conversation in which I asked him what his goals were at that point, and he adamantly reiterated that he wanted to beat the cancer—to win. In other words, he had come to equate dying with “losing.”
Between his diagnosis and this difficult conversation, Dominic had lived nine years. He had seen his daughter grow from a child to a young adult; joined cancer support groups locally and nationally; had become a spokesman, mentor, and inspiration to countless men sharing his diagnosis; and had changed literally hundreds of lives, including mine. Yes, he was dying, but he still had agency, and his life would continue to influence the lives of those he knew, even after his death. This was not a war but a journey, an evolution of his life that opened the door to new relationships and an appreciation for the time he had left. Even though he did not see his cancer struggle this way, he was living it. He was able to live a meaningful life with cancer.
Steele’s prostate cancer recurred almost 12 years ago. We were able to control his cancer and stay ahead of cancer symptoms for many years. As a result, he was able to maintain his many work, family, and social responsibilities. He was a former college wrestler and army veteran, a pillar in his community, and grounded in the security of who he was and what he meant to the people around him. As his cancer advanced, we discussed chemotherapy as an option, but he declined initially because his foremost goal was to maintain his quality of life. We did eventually use chemotherapy as his disease became more symptomatic, but with significant side effects and only a modest benefit. My hope was to keep him alive long enough to receive a new radioligand targeted therapy that would soon become available. Instead, he decided on hospice. Although I respected his choice, it seemed premature to me, given how competitive he was in every other aspect of his life. Nonetheless, he was ready to move on from chemotherapy. He lived another 6 months, during which he was able to visit with his many friends and family, transition his business responsibilities, and spend some memorable time together with those he cared about, including me. After I had seen him for the last time, I could not help but think that he had lived and died with cancer on his terms, another victory.
I have many patients who still see cancer as a struggle, a win-or-lose proposition. But patients like Dominic and Steele allow us to see how the terms of engagement can change—from a question of when they will die to one of how they will live. I remember one moment during my last conversation with Dominic when he asked me point blank, “Am I going to win against cancer?” Without hesitation, I replied, “Dominic, you’ve already won.”
Daniel J. George, MD