“What is a reasonable plan of follow-up for patients with cancers for which early detection of metastatic disease offers no advantage?” Posing that question during his Presidential Address at the 2018 Society of Surgical Oncology (SSO) Annual Cancer Symposium, Kelly M. McMasters, MD,PhD, acknowledged, “there are some types of cancer for which routine surveillance with tumor markers and imaging studies is warranted because reasonable salvage therapies are available that can extend survival with a good quality of life.”¹ If, however, “there are no salvage therapies that offer a reasonable chance of prolonged survival or cure when asymptomatic recurrence is found,” he said, “why bother to look very hard to find bad news?”

Dr. McMasters is the Ben A. Reid, Sr, MD, Professor and Chair of the Hiram C. Polk, Jr, MD, Department of Surgery at the University of Louisville School of Medicine in Louisville, Kentucky. More than 1,900 academic and community-based cancer surgeons representing 47 countries attended the symposium in Chicago.

One Caveat

“Surveillance carcinoembryonic antigen (CEA) levels and computed tomography (CT) scans make sense for patients with colorectal cancer, because some patients with hepatic metastases can undergo potentially curative liver resection,” Dr. McMasters explained. “However, what possible benefit can there be for early detection of asymptomatic recurrent pancreatic cancer? Resection of pancreatic adenocarcinoma is almost always a palliative operation,” he noted, and “almost all patients will eventually die of the disease. Why do we perform CT scans and blood tests every 3 months? So we can administer palliative chemotherapy prior to the development of symptoms? Well, you can’t palliate a patient who is asymptomatic.”

There is an important distinction between tests to detect actionable local or regional recurrence vs systemic recurrence.

— Kelly M. McMasters, MD, PhD

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The question could be asked for patients with “any other type of solid tumor we resect for which there are no effective salvage therapies or for which there is no evidence that early detection of asymptomatic recurrence is any better than waiting until the patients are symptomatic,” Dr. McMasters said.

“I will add one caveat,” he continued. “There is an important distinction between tests to detect actionable local or regional recurrence vs systemic recurrence. Surgeons are locoregional disease control specialists. We sometimes cure patients by virtue of the fact that some cancers have not progressed beyond the local, and regional local disease we resect. Failure of locoregional disease control can cause untold misery for our patients, and salvage procedures when the locoregional disease is detected early can sometimes prevent or mitigate this misery.”

Driven by Symptoms, Not Protocol

“For patients with cancers for which there is no good rationale for early detection of recurrence, I tell them we will proceed with the assumption that they are cured of their cancer, unless proven otherwise,” Dr. McMasters said. “Almost all patients understand this philosophy and agree to follow this plan.”

It is imperative that we teach physicians how to initiate appropriate end-of-life discussions well before the end of life.

— Kelly M. McMasters, MD, PhD

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Those who do agree continue regular office visits, when Dr. McMasters can “do a physical examination and, most importantly, take a little time to talk to them. I ask about their quality of life and activities and may discuss anything from fishing to family matters. Patients know they should call immediately if they develop new symptoms or problems between office visits. Decisions about imaging and other tests are driven by symptoms, not by protocol. If the patient is not comfortable with this watchful waiting strategy, we decide together on a reasonable surveillance plan.”

Many of these patients “will relapse and die of their cancer, but not all,” Dr. McMasters said. “It is hope that sustains these patients. Hope is what allows them to experience the greatest quality of life after treatment of potentially curable cancers, even if that potential is small. I think it is a laudable goal to prolong the time until the patient must face the reality of terminal disease,” he stated.

“Certainly, the best quality of life occurs when the patient has no symptoms and no knowledge of recurrence. This is the survival time we should strive to prolong,” he added.

‘A Good Operation’

“In this dayand age of personalized cancer therapy, targeted agents, immunotherapy, multidrug cytotoxic chemotherapy regimens, and a dozen different ways to deliver radiation therapy, it is easy to forget that the original cancer therapy is still the most effective treatment for solid tumors. In many cases—even sometimes hopeless cases—a good operation is still the single best thing we can do for our patients,” Dr. McMasters reminded his colleagues.

“Multidisciplinary treatment is generally considered to be the best approach to cancer patient care, and most of the time, this is certainly true. Yet how many times have you seen patients with incurable cancer, who have had innumerable chemotherapy regimens and radiation therapy administered right up to the time of their demise, when everyone knew these treatments were futile? Lest we start throwing stones from inside our glass house, we need to critically evaluate the value of all that is done in the name of surgical palliation as well,” he commented.

Touch of Compassion

“I am regularly astounded at how frequently patients and their families, yearning for someone to tell them the plain truth, have encountered physicians who have made the truth so elusive. Sometimes, what is needed is one good doctor who knows the patient well enough to help make the right decisions. This includes the decision to stop chemotherapy and institute palliative care,” Dr. McMasters said.

The best quality of life occurs when the patient has no symptoms and no knowledge of recurrence. This is the survival time we should strive to prolong.

— Kelly M. McMasters, MD, PhD

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“Patients are forever grateful if you tell them the truth, especially if you summon a touch of compassion when you deliver the bad news. Patients do not always expect miracles, but they appreciate even the smallest signs of concern, which are easy for busy clinicians to overlook,” he remarked.

“The most challenging—but perhaps most rewarding—part of being a surgical oncologist is to help ease patients over to the other side with dignity. I let my patients with incurable cancer know that if it gets to the point where further therapy will cause more harm than good, I will tell them. When it gets to that point, I do tell them. Many times, patients are relieved and just want someone to give them permission to stop treatment,” he said.

You Have a Choice

“The available evidence suggests that palliative supportive care enhances not only quality but also duration of life. It is imperative that we teach physicians how to initiate appropriate end-of-life discussions well before the end of life,” Dr. McMasters stated.

In some cases, patients and their families might say they want everything possible done to keep fighting cancer. “This is where being a good doctor comes in,” he said. “I guarantee that no one wants to suffer from toxicity caused by futile therapy, and no one wants to watch his or her family member go through this. These are the hard conversations you shouldn’t avoid. This is where you can make the difference between death with dignity and death with indescribable misery,” Dr. McMasters said. Dr. McMasters discussed how his approach to cancer patient care has been influenced by his experience in caring for his son, Owen, who died at age 16 after a long battle with leukemia.

“You have a choice,” he told his colleagues. “You can be a surgical oncologist who cuts out cancer and delegates the decisions about appropriate follow-up testing and palliative care to others. Or you can be a good doctor and do the right thing. You can avoid the difficult conversations, or you can understand the fundamental difference between cancer treatment and patient care.” ■

DISCLOSURE: Dr. McMasters reported no conflicts of interest.

REFERENCE

1. McMasters KM: 2018 Presidential Address—Society of Surgical Oncology: The Fundamental Difference Between Cancer Treatment and Patient Care. Ann Surg Oncol 25:1449-1453, 2018.