Local Option

The Rational Use of Local Therapy in Patients at High Risk to Die of Metastatic Progression

Daniel J. Boffa

Disclosures

J Oncol Pract. 2018;14(6):344-349. 

In This Article

Abstract and Introduction

Abstract

On occasion, clinicians may be motivated to offer local therapy (eg, surgery, radiation, ablation) to patients with advanced cancer in the hope of prolonging survival (as opposed to palliating a symptom). An appropriately informed discussion of risks and benefits should push clinicians to reflect on the rationale for use of local therapy in a patient who is far more likely to die as a result of systemic progression. Ultimately, the justification for local therapy in advanced cancer must be based on several assumptions of what a patient's cancer will and will not do. The following is an attempt to provide the framework for patients and their care teams to collectively consider the assumptions surrounding the use of local therapy and the potential consequences of being wrong.

Introduction

Stage-specific guidelines currently define the optimal treatment of an unprecedented breadth and depth of cancer scenarios. However, not all tumors behave as predicted by their stage classification, and some patients survive despite a poor prognosis. As a result, clinicians may be tempted to deviate from treatment guidelines in response to observed (or anticipated) favourable tumor behavior.

An optimistic assessment of tumor behaviour may, on occasion, motivate clinicians to use local therapy (eg, surgery, radiation, ablation) to prolong survival in a patient in whom staging parameters suggest a high risk of systemic progression. The justification for local therapy in this setting involves a series of improbable (but not unreasonable) assumptions. The concepts described in this paper (driver, balance, and switcheroo) are meant to facilitate an open dialogue between clinicians and highly selected patients about the appropriateness of local therapy despite a high(but not prohibitive) risk of fatal systemic progression. This paper discusses the use of local therapy for curative intent, as well as attempts to prolong survival without cure (ie, lesion-specific cytoreduction). The use of local therapy to palliate a symptom (without the intention of prolonging survival) is an important but separate topic and is not discussed.

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