Reply to the letter to the editor: ‘The hard road to patient-centered care: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer?’ By P. Trendsz et al.
Authors: A. Sobrero, J.-Y. Douillard
Journal: Annals of Oncology (2018)

P. Trensz et al. [1.Trensz P. Calvel L. Kurtz J.E. The hard road to patient-centered care: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer?.Ann Oncol. 2018; 29: 1601Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] in their Letter to the Editor of Annals of Oncology discussed our Special Article, a meeting report addressing 'The hard road to data interpretation: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer' [2.Sobrero A. Grothey A. Iveson T. et al.The hard road to data interpretation: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer?.Ann Oncol. 2018; 29: 1099-1107Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. They cite a sentence of our conclusion where we state that 'the main driver for the duration of adjuvant treatment were treatment choice and very importantly the patient's attitude to his/her disease'. In the IDEA project, the pooled analysis showed that a reduced duration of adjuvant chemotherapy was associated with an important reduction of long-term toxicity whereas the 3-year DFS difference was very small with no 'clinically significant' reduction. This may, however, matter for an individual patient and should be clearly explained and discussed with each individual patient. P Trendsz et al. consider this situation as a 'clinical equipoise'. This would be correct if there were some degrees of uncertainty but the efficacy is clinically preserved (absolute difference in 3-year DFS is 0.9% on 13 000 patients) when the toxicity is highly significantly reduced in IDEA. We fully agree, with these results in mind, that clear information on the Pros and Cons has to be discussed with the patient for him to be part of the final choice in terms of treatment duration. Based on a limited-size poll of 45 colon cancer patients, one-third of patients would have chosen to accept a reduction of 1%–2% in cure rate only and two-third a risk reduction of >2%: based on their response they were retrospectively grouped in 'fighters' (risk of 1%–2%) or 'fatalists' accepting a higher risk for a benefit of reduced toxicity. P Trendsz et al. consider that the 'chosen metaphor' is inappropriate and might influence decision making, inducing a feeling of guiltiness. The terms of 'fighters' or 'fatalists' were used to group the patients (it was more convenient than A and B) for the discussion of the panel and does not imply a judgement on the patient's individual choice, that in all cases is to be respected. The authors misunderstood our intention when they state, 'The main decision … should be the patient rather than predefined patient's attitude'. The attitude is not predefined and the choice made after a clear information and discussion with the patient, to answer and clarify possible questions. The groups of 'fighters' and 'fatalists' were built a posteriori for the sake of the discussion. The decision is never made by the oncologist only, but should emerge from a frank patient/doctor relationship and dialogue where the patient's personal preferences and values are the final drivers of the choice. All expenses relating to the special symposium were covered by ESMO (no grant numbers apply). ESMO provided funding for writing support in the preparation of the manuscript.