A Good Life
Authors: Robert E. Fisher
Journal: Journal of Clinical Oncology (2009)

DOI: 10.1200/JCO.2009.22.5854 Many years ago, I shared in the care of an astute primary care physician who eventually died from metastatic renal cell carcinoma. He maintained his intellect and composure until the end, and spent much time thanking us for providing he and his family “a good death.” Although I am sure that this physician did not originate this term, he certainly used the term before it had gained its current common use. Recently, I had the privilege to be one of a few medical oncologists at a 4-day retreat for cancer survivors: The Ninth Annual Life Beyond Cancer Retreat in Tucson, AZ, in December 2008. Having become immersed in the issues that our patients face at this conference, I realized that we as a profession should devote ourselves to assisting our patients in striving for a good life with as much relevance and purpose as we assist our terminal patients in the dying process. My current thoughts are new to a practitioner whose career started more than 20 years ago. I can recall advising patients finishing breast cancer adjuvant chemotherapy. At that point in my early career, I thought these patients would be over cancer and normal again soon after their last WBC nadir and recovery from treatment-induced alopecia. I thought surely their lives were restored and their places with family, friends, and work would become usual within only a brief period of a few weeks at most. Though my ideas about recovery were certainly naive, I venture that few of us in our profession have fully considered the burden of survivorship that our patients face. I believe that physicians practicing medical oncology maintain a narrow view of our patients’ recoveries. We view recovery from the standpoint of frequency of office visits and treatment dates. But from the patients’ perspective, as active treatment ends, their cancer experience may be just beginning. I can recall many patients finishing adjuvant treatment, with its scrutiny of minor symptoms and attention to crowded treatment schedules, and then being puzzled by what happens to them next. Suddenly, the devoted attention of their physicians, oncology nurses, and other support staff disappears. On more than one occasion, patients have described this aftertreatment survivorship as falling through an empty void. Why is it that we, as medical oncologists, are not there for our patients to avoid this freefall? I think this is due to our errant, excessive attention to those on treatment, defined by us as some form of intravenous therapy. Witness that the National Coalition of Cancer Survivors was founded in 1986, yet the term “survivorship” as it applies to psychosocial and long-term health issues after cancer diagnosis did not appear in a published abstract or title in Journal of Clinical Oncology until 2002. Though we as physicians may see our returning patients as the fortunate ones, we need to realize the trauma experienced by many patients in their years as cancer survivors. Our patients live with the fear of relapse and disease progression. Their cancer fears may inhibit their return to a meaningful life, let alone achievement of normalcy. Their fear of relapse may, in fact, prove more debilitating than what a state of relapse becomes to other patients. We must realize that our patients’ return office visits often function to recharge them and give them security and comfort until the next office visit some months in the future. Each return visit potentially confirms the gravity of their diagnosis, connects with a memory of a difficult time in their life, and reaffirms that they are safe to continue with a redirected life. Our patients leave our offices hopeful to be reassured of their freedom from cancer’s reoccurrence. Then the process of uncertainty builds again with time, as the next oncology visit approaches some months later. These and other issues of survivorship change our patients’ lives forever. Just as we follow our patients diligently for disease relapse, we should use the same diligence in our encouragement of all surviving patients to resume meaningful living. Rather than assuming that our patients will return to their former lives, we should ask, “How has having cancer changed you?” This question may assist in healing and recovery. From this may come a more meaningful life that incorporates their cancer experience in their new paradigm. Though we may be concerned about negative prognostic factors associated with a given patient’s cancer, each patient in remission is a longterm survivor until their cancer proves otherwise. JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 27 NUMBER 31 NOVEMBER 1 2009