Sometimes, progress brings uncertainty. The past few years have seen a steady increase in the number of drugs and other approaches to cancer treatment such as immunotherapy that can be used to treat cancer. Most of these new approaches do not cure cancer when given as a single therapy. Nevertheless, many of them are very effective at inducing a temporary shrinking of the cancer. For many cancers, we have a number of such treatments available. From a physician’s point of view, these new treatments create more options for patients. But they raise a question that cancer doctors have struggled with for decades. Do we …
“Lump” treatments together and use them all up front at the time of diagnosis;
“Spread” treatments out over time and use them one by one as the patient needs them.
There are advantages and disadvantages to both approaches.
Advantage – There is evidence that using multiple treatments that kill cancer cells by different mechanisms can result in long-term remission or even cure that can’t be achieved if the drugs are used one by one.
Disadvantage – Giving multiple treatments together often increases a patient’s side effects, and leaves fewer options if the cancer returns.
Advantage – Giving treatments one by one is generally better tolerated by patients rather than using them together, and provides a series of options once a given treatment is no longer working.
Disadvantage – Giving treatments as single agents reduces the chance of a prolonged period of remission or even the possibility of cure.
As with so many questions in cancer medicine, the clearest answer as to whether to lump or spread cancer treatments in a given scenario comes from clinical trials. The challenge is that trials comparing lumping to spreading are difficult to conduct and often have to run for many years before we know which approach is better for a given type of patient. Indeed, for some cancers, it takes decades before we know if we have really cured patients by lumping treatments together. By the time such studies mature and provide us with an answer, we often have new and better treatments available.
The professional debate on which approach is best can be lively with informed experts often disagreeing. When making a recommendation for an individual patient, cancer doctors weigh the available data and use clinical judgment that takes into account the unique health and personal needs of that patient. I am more likely to lump treatments together and aim for a prolonged remission or the possibility of a cure in a young patient who is otherwise healthy and can tolerate the side effects of such treatments. For an older patient with multiple other health issues, I am more likely to spread treatments out so they are better tolerated and only used as needed. The personal perspective of the patient and their loved ones is also important. Some are willing to risk severe side effects for even a small chance of prolonged remission or cure, while others elect to focus on quality of life.
When determining how to leverage progress in cancer research to help an individual patient, there is still much to be said for the art of medicine. The words “lump” and “spread” are sometimes used in discussions between a cancer doctor and a patient in describing a cancer. A thoughtful and informed doctor also weighs the available data, and works with the patient and the family to use these words in another way, so together, they can decide whether to “lump” or “spread” treatments is the best approach.