1. Harpham, Wendy S. MD

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For decades, patients have complained about the slash-burn-poison approach to curing cancer. So you'd expect newly diagnosed patients to jump at the chance to defer-and maybe avoid-the toxicities of cancer treatment without jeopardizing their chance for cure.

WENDY S. HARPHAM, MD... - Click to enlarge in new windowWENDY S. HARPHAM, MD. WENDY S. HARPHAM, MD, an internist, cancer survivor, and author, has been writing this award-winning column since 2005. Her books include

Yet when patients with potentially curable cancers are candidates for active surveillance (for example, men with low-risk prostate cancer), some turn it down to proceed with therapies with known side- and aftereffects. Why? I'm not suggesting they're making a poor decision. I'm simply asking because such patients face unique obstacles to informed decision-making.


Many patients never heard of active surveillance. Others confuse it with watchful waiting. Either way, today's patients got the cancer memo that early detection saves lives. "Cancer" falls in the same category as "leaky gas lines"-a life-threatening problem that demands immediate action. Deferring cancer treatment just feels wrong. So patients who learn they have a potentially curable cancer and then hear you recommend active surveillance may initially respond: "What? Let my cancer grow?"


We know that the words patients first hear can affect how they hear everything that follows. If you preface any mention of active surveillance with reassurance that you are only considering curative approaches, the calming effect of "curative" may help patients perceive the deferral of cancer treatment as a benefit-and not as a sign that you've given up.


In your subsequent discussion, how you frame the mechanics of active surveillance can affect how they perceive their overall situation. You can describe the rigmarole of periodic exams and tests, including biopsies, as "the way we'll pick up a transformed cancer early enough to cure it." Or you can present it as "the way we'll keep confirming that your cancer is remaining low-risk and does not need treatment." The latter presentation, while equally accurate, may facilitate patients' ability to understand-and believe-that their cancer may never pose a problem.


With that optimistic outlook as the foundation, you can then address the real possibility that their cancer may, indeed, transform and need treatment. The uncertainty about what will happen in the future lies at the heart of patients' uncertainty about what to do now. The power of "prognosis" can help you make the case for active surveillance: "Your long-term prognosis is the same, whichever path you choose-whether you start cancer treatment now or later, if your cancer becomes more aggressive."


Patients can understand that fact, yet not quite believe it applies to them. Your acknowledging the cognitive dissonance may help patients feel less distressed by it-and more normal. That, in turn, encourages patients to find the patience to make a rational decision and not just go with their gut. "It can take a while to believe the prognosis is the same, because it's counterintuitive. But large studies have proven it's true."


Despite the vital role of statistics in weighing treatment options, few (if any) patients make thoroughly dispassionate decisions. Because patients' emotions necessarily shape how they process medical information.


Patients may project how they'd feel if things ended up poorly. And some may conclude that they'd experience more regret after choosing active surveillance, having given their low-risk cancer cells more time to transform.


The cellular drama can loom large in the mind of newly diagnosed patients. Even for people who are usually laid back and optimistic, innocent muscle twinges may trigger fleeting thoughts of cancer-filled lumps growing like Jiffy Pop bags over a fire. Such imaginings stir anxiety and anticipatory regret, emotions that create a sense of urgency to begin treatment.


That urgency reminds me of times people said I was courageous to do chemo. What's really brave is not treating cancer. It takes courage to decline low-yield treatments to optimize your remaining time. It takes courage to decline potentially curative treatment to avoid over-treatment.


Along with courage, patients need support, especially if between office visits they're hearing criticism of active surveillance from quarterbacking family, friends, or social-media contacts. Perhaps it would help to offer them a ready response to those concerns: "You're deferring treatment, not your chance for cure."


Once all the facts have been shared, the decision about active surveillance hinges on patients' ability to handle two challenges: the ongoing demands of the periodic testing and the reality of living with an untreated cancer.


Even for those patients who ultimately choose active surveillance as their best option, feeling confident of that decision doesn't necessarily make it easy. Some patients may need brief counseling and/or regular support to calm their anxiety enough to get on with their life and enjoy the benefits of deferring cancer treatment.


Every day, patients look to you for insights and guidance regarding their treatments with intent to cure. The following steps may help when circumstances make active surveillance an option:


* State the mission: "Our mission is to determine the best option for you, whatever that may be."


* Preface your introduction: "We are only discussing curative approaches."


* Highlight the advantage: "Active surveillance is your only curative option that defers treatment to avoid overtreatment."


* Normalize expectant management: "Surveillance is a time-honored approach in medicine. We often monitor certain diseases and start treatment only if testing or symptoms signify a change that shifts the risk-benefit ratio in favor of treating. (For example, certain cases of heart valve diseases, arthritis, and chronic viral infections.)"



Today, relatively few patients with potentially curable cancers are candidates for active surveillance. That will likely change as diagnostics and therapeutics continue to advance. By figuring out how to address the unique challenges faced by such patients, you ensure that you'll know the answer to why some choose to proceed with cancer treatment: It's the best option for them.