Top Hope Among Advanced Cancer Patients Is Not Cure

Caveat: Survey Pre-dates Immunotherapy Whirlwind

Nick Mulcahy

February 01, 2019

What do American metastatic cancer patients hope for from their cancer treatment? Most commonly, they desire a good quality of life, according to a rare large survey on the subject in this patient population.

Cure was not even in the top five responses among the 216 participating patients, report Jeremy DeMartini, MD, Department of Psychiatry, University of California, Davis, and colleagues in a new study published in the January issue of the Journal of Pain and Symptom Management

The most prevalent hope (42% of the total responses) was maintaining quality of life.

Life extension (32%) ranked second, followed by tumor stabilization (26%), remission (20%), reaching a milestone (such as seeing a child married; 14%), and "unqualified" cure (12%). Another 5% had hope for a cure that was "tempered by realism" (such as hoping for a cure, but admitting it was not possible). Thus, even if both cure categories were combined, they still only accounted for 17% of the patients' expressed hopes.

However, the new study has an important caveat: the survey was part of a trial conducted from 2012 to 2014, before immunotherapy received widespread publicity — and hype — about improving survival and potentially curing some patients with advanced cancer.

In short, the survey data may be dated, to some extent.

Times have changed, acknowledged DeMartini in an email to Medscape Medical News.

"Immunotherapy and the promise of other new treatments for many types of cancer bring hope to patients and physicians alike," he said.

Clinicians who want to put the survey results into practice may struggle, suggested Bishal Gyawali, MD, PhD, of Brigham and Women's Hospital in Boston, in a comment posted on his Twitter feed about the new results.

That's because, in terms of drug treatment, quality of life is not well reported, said Gyawali, who was not involved in the study.

"Unfortunately nearly half of cancer drug trials don't even include QoL as an endpoint and, those that do, a quarter won't report it," he tweeted, citing a 2018 study.

However, the study authors do not discuss this failing. 

DeMartini said that cancer drugs "are not side-effect free" and that advanced cancer patients and their physicians must balance the related risks and benefits.

The authors say that "little is known" about advanced cancer patients' hopes for their treatment. 

Other studies on the subject have had shortcomings, they say, citing small sample sizes, inclusion of patients with serious illnesses other than advanced cancer, andinclusion of small subsets of cancer types.

Asked if the lack of substantial data was a surprise given the importance of the matter, DeMartini responded: "Yes!"

Authors Concerned About Hopes for Cure 

The new study comes from the VOICE trial, a patient communication study. The investigators surveyed 265 patients at the University of Rochester and University of California, Davis; these patients had a variety of advanced cancers, including 50% that were categorized as "aggressive."  

After 3 months, 45 patients died and four dropped out of the study, leaving 216 patients for the final results. 

At baseline, patients' hopes were elicited in interviews by investigators, who asked the open-ended question, "What are you hoping for…in your cancer treatment?" 

Subsequent interviews at 3 months yielded another set of answers, but the relative prevalence of the responses "did not change substantially" from baseline, say the authors.

In other words, quality of life was still the top hope in the second interview. And cure was still toward the bottom.

The study locations are one of its limitations. The authors explain: "Our results may not be generalizable to the entire population of advanced cancer patients because patients were recruited from only two geographic areas, and the sample was predominately white, Christian, and well educated."

The study used open-ended interviewing, which the team transcribed and analyzed. This resulted in eight categories of hopes, as noted above, into which 95% of patients' responses could be categorized at both the baseline and 3 months.

The study also asked patients about the discussions they had concerning their hopes for cancer treatment, and with whom they discussed these hopes. 

Most patients reported discussing treatment hopes with partners, family/friends, and oncologists. A minority reported discussing hopes with nurses, primary care physicians, clergy, or support groups. 

In logistic regression analysis, unqualified hopes for cure were more likely in younger patients and those who did not discuss their hopes with primary care physicians, write the authors.

DeMartini explained: "While primary care physicians don't typically directly treat cancer itself, they may have a longstanding and holistic relationship with the patient that is helpful in focusing or reframing hopes."

The study authors hope clinicians ask patients about their hopes for treatment — in order to address probable reality. The authors repeatedly state their concern about the "sizeable minority" of patients who express hope for a cure, despite having metastatic disease.

The study was supported by the National Cancer Institute.DeMartini, his coauthors, and Gyawali have disclosed no relevant financial relationships.

Journal of Pain and Symptom Management. Published online January 2019. Full text

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