When Should Oncologists Use the Words Hope and Cure?

Advances in cancer diagnosis, screening, and treatment have substantially improved the 5-year survival rates of most cancers over the last 30 years. Long-term survivors of cancer are increasingly common, and research is increasingly directed at helping people live well after a diagnosis of cancer. These advances have provoked optimism among oncologists, but many still hesitate to use the word cure with their patients. In their article published in this issue of the Journal, Corn and colleagues (1) tested the hypothesis that oncologists are reluctant to use the terms hope and cure in journal articles. The authors analyzed 13 363 articles classified as primary research, editorials, or narrative essays published in the Journal of Clinical Oncology (from 2000 to 2018) or JAMA Oncology (from 2015 to 2019) and counted the numbers and proportions of articles, and of sentences, that included the words hope or cure. Overall, the words hope and cure were used infrequently and mentioned less often in primary research articles than narrative essays. Use of both terms diminished over time despite increasing cancer survival rates. The investigators concluded that the time has come for oncologists to embrace the words hope and cure. To consider this, it is necessary to distinguish how oncologists communicate in journal articles vs how they communicate to patients. Journal articles typically describe groups of people, and the terminology and syntax are aimed at a target audience of other oncologists. Given neither hope nor cure has an accepted definition in oncology, it is not surprising these words are seldom used in publications. When oncologists communicate with patients, the audience is an individual with cancer and the language used needs to be clear, easy to understand, and reassuring. In cancer care, hope has been defined as “the confident but uncertain expectation of a future good that appears realistically possible and is personally significant to the individual” (2). Having things to hope for is important for all people affected by cancer, and cure, or at least prolonged survival, is often the primary target of that hope. Oncologists are able to foster and deplete hope through their communication of information about diagnosis, treatment, and prognosis. In the setting of advanced cancer, oncologists can help patients redirect their hope, for example, towards hoping for dignity, symptom relief, and time with their family. It is unlikely that use of the word hope is necessary to convey hope. For example, physician behaviors identified by patients as hope-giving include combining honesty and empathy, framing hope in a wider context than cure, and emphasizing achievable treatment goals (3). Knowing when and how to use the words cure and cured in conversations with people affected by cancer is much more complicated. The American Society of Clinical Oncology defines cancer cure for an individual in its cancer survivorship booklet as “when a person’s cancer has not returned for at least 5 years after treatment” (4). Another definition of cancer cure is when the mortality rate of people diagnosed with a certain cancer returns to the level expected in the general population of the same sex and age (5). For most cancers, this is much longer than 5 years after treatment. For example, women with estrogen receptor– positive, early-stage breast cancer have a persistent risk of recurrence and death from breast cancer for at least 20 years after their initial diagnosis (6). Before encouraging oncologists to use the word cure more often, we need a better understanding of what cure means to oncologists and patients. For example, should there be an agreed threshold for the time from diagnosis and/or estimated risk of recurrence beyond which oncologists should be comfortable using the word cure? In a survey of 117 American oncology clinicians, 81% responded that they were “hesitant to tell a patient that they are cured,” and 63% responded that they “would never tell a patient that they are cured” (7). Only 36% of respondents were “comfortable telling a patient that they are cured within 05 years after completing the initial phase of their treatment,” with most respondents wanting 6-10 years or longer before using the word cured (7). Conversations between oncologists and their patients with an early-stage cancer stereotypically focus on the risk of recurrence with and without additional treatment. Many of these patients are cured, but their risk of future recurrence—even when very small—makes oncologists reluctant to use the word cure, fearing it will be interpreted as a promise, and particularly one that might be broken. Instead, we have become familiar using less specific words and phrases, including curable, curative