When do we stop talking about curative care

657 TRUTH AND HONESTY ARE DELICATE ISSUES in the world of cancer care. What cancer patients and their loved ones should be told and how they should be told it remains a challenging issue for anyone caring for them. While it is easy to condemn lying and to embrace honesty, brutal declarations of the truth can be damaging, and based on what my patients tell me, are not uncommon. In the abstract, it is easy to assert that all patients have a right to know to details of their condition and their prognosis—and surely they do—but it becomes more complicated when the patient does not want to know, or if the patient is ambivalent. Denial and hope can be key elements of a patient’s strategy for maximizing psychological quality of life in the face of a devastating diagnosis. Building honest relationships and giving patients the information they want or need while respecting their limits and their need for hope represents a challenge confronted by everyone who works with these individuals. However, all too often, the prioritization of hope or the perceived psychological frailty of cancer patients become excuses to withhold fundamental information that patients need in order to make plans for their care and for their future. As an oncologist, first in training and now in practice, I have been very interested in the question of why we providers sometimes have so much difficulty being honest with our patients. This issue of Innovations explores an effort to integrate palliative care upstream at a cancer center, specifically for patients with advanced lung cancer who may still be pursuing treatment for their disease.a This effort brings up the question of when and how, we, as oncologists, and our institutions as cancer centers, founded to fight the cancer, shift our language away from talking about curative treatments. At what stage do we know we are not talking about a cure any more? And what do we mean by cure—a remission that lasts 5 years? How do we share this knowledge (often filled with caveats and probabilities, but no prognostic crystal ball) with our patients? Pragmatically speaking, for patients with stage III and IV non-small–cell lung cancer, the outlook is grim. While some patients with IIIa disease can be cured, as can fewer patients with IIIb cancers, stage IV disease (such as extensive stage small cell lung cancer) is generally considered incurable. Most such patients are dead within a year and only 1% or 2% are alive 5 years after diagnosis.1 I believe that for any patient with metastatic disease, it should be made clear that this is a terminal illness and any therapy is aimed at reducing symptoms or extending life for some limited period of time. This is important, in part, because current chemotherapy for metastatic lung cancer only extends survival for approximately 2 to 3 months. The length of time patients spend receiving chemotherapy is longer than the amount of time the average patient gains as a result of chemotherapy. There is evidence that chemotherapy improves quality of life in patients with lung cancer, but the quality-of-life experts I know are not entirely impressed by these data. Patients need to balance the pros and cons of chemotherapy before making a decision, and bandying about notions of cure would be very misleading. So how does this language of curative treatments creep into a setting of metastatic lung cancer? To sustain hope? To justify chemotherapy? To avoid upsetting the patient? To sustain the oncologist’s own denial about how little progress we have made in this area of oncology? Because