“There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something tomorrow.”
–Orison Swett Marden
I was informed that my patient, a 58-year-old man recently diagnosed with pancreatic cancer, and his wife were becoming impatient waiting for me in the exam room. Due to the haste in scheduling the appointment, health documents and imaging files were not available for review in advance. During the initial few minutes of the visit, the couple seemed obviously annoyed at having to repeat details they have told multiple times. I surmised that the patient had seen other physicians regarding his recent diagnosis, as he and his wife seemed knowledgeable regarding his current condition and treatment options. He also did not express the often-seen shock and disbelief of being diagnosed with this difficult malignancy, but rather a sense of anger that this cancer has chosen him to afflict.
He knew his situation was serious; his tumor, despite having no evidence of metastases, was locally advanced with extensive involvement of surrounding vasculature. My treatment recommendation was no different from his prior opinions. I explained to him that, based on published data and my personal experience, there was a 15% to 20% chance for surgical resection. Their expression suddenly changed as he and his wife became attentive and exuberant. He quickly shouted, “That is the best news I’ve heard yet.”
As it does not seem possible to quantify a value or an outcome that differentiates between hope and expectation, I would submit that it is completely subjective.— Aaron Sasson, MD
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Afraid I had failed to convey the facts, I repeated the hurdles required to be a surgical candidate: no progression of disease either locally or development of metastasis, along with the technical considerations associated with major vascular resection. I further included a brief discussion regarding the complications of the surgery, as well as the oncologic outcomes. Despite all this, his enthusiasm persisted. As we concluded the visit, he said, “Thank you. You are the first one to give me any hope.”
He was my last patient of the day, which allowed me to reflect on our interaction. Although he seemed excited and pleased to have “hope,” that was not my intention. When dealing with patients who have cancer, I try to provide realistic expectations, neither optimistic nor pessimistic. Following this appointment, I asked the accompanying medical entourage (residents, students, and nurses) if the discussion was accurate and balanced. Although I have no objection to providing hope, false hope on the other hand is undesirable.
Hope vs Expectation
Very few medical conditions provoke the level of anxiety of a cancer diagnosis. It seems like human nature for patients (and their families), as they grapple with this life-altering event, is to understand the prognosis as a euphuism for “how long do I have to live?” Our only recourse is to use statistics, data compiled of a population, which, unfortunately, are not applicable to an individual patient.
So, at what response rate, life expectancy, oncologic outcome, is there a difference between hope and expectation? A patient with stage I colon cancer could reasonably expect a greater than 95% survival. In contrast, a patient receiving systemic chemotherapy for metastatic pancreatic cancer would statistically have a 30% response rate (best available data) and a median survival of 1 year. A patient with the latter condition would naturally “hope” to be one of the few responders and want to “beat the odds.” I have yet to meet a patient who would interpret the latter scenario as a 70% chance of failure.
As oncologists, we have a responsibility to provide accurate information; as such, we can let the patient (and the family) make their own inferences. As it does not seem possible to quantify a value or an outcome that differentiates between hope and expectation, I would submit that it is completely subjective.
Desperation and Hope
Clearly, the more aggressive the malignancy, the more dire the prognosis. In my experience, such patients often report encountering nihilism from medical professionals. Patients, and their families, are often desperate for treatment options, even with the smallest chance of success, ie, hope. There is no doubt that patients wish to be hopeful, as they often agree to cancer therapy that carries a low rate of success. As oncologists, we facilitate providing hope, whether intentional or not, as we offer patients second- and third-line therapies, with decreasing efficacy. The combination of oncologists wishing to provide options and patients “grasping at straws” is evident by the number of patients receiving chemotherapy within the last few weeks of life, along with patients undergoing extreme surgical interventions with advanced disease.
One could argue that the typical profile of a patient enrolling in a phase I clinical trial is that of despair and hope. Despair, in the sense that they have failed to respond to standard treatment or that none exists, and hope for a potential “breakthrough” in an otherwise unproven and untested “experimental” therapy. Patients consent to these trials as an effort to combat their cancer for one reason: hope.
The Universal Will to Live
Fyodor Dostoevsky once said, “To live without hope is to cease to live.” Are there consequences to nihilism and denying patients hope? The will to live appears to be a universal human trait and especially poignant in patients with cancer. I suspect it is one of the determinants for which patients seek treatment, even for advanced cancer, when long-term survival is not possible. Surprisingly, or not, there are few scientific data regarding hope and cancer. In a report of 120 interviews with patients with terminal cancer, almost all patients identified hope as a significant existential concern.1 Studies demonstrate that hope is an important factor for patients with their psychosocial needs and quality of life, and, furthermore, a lack of hope is associated with depression.2 I have observed similar effects of hope and lack thereof, albeit anecdotally.
Hope: A Light in the Darkness
Desmond Tutu once said, “Hope is being able to see that there is light despite all of the darkness.” Although I still strive to present data regarding treatment options realistically, if I provide hope in addition, I view that as an added benefit. Improving a patient’s emotional well-being should always be encouraged, although not at the cost of providing false hope. As oncologists, we are frequently offering treatment options, even in the bleakest of clinical situations. Offering patients a treatment option is the equivalence of “prescribing hope.” ■
DISCLOSURE: Dr. Sasson owns stock or other ownership interests in Sanguine Diagnostics and Therapeutics and was a paid speaker for Novartis.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
1. Greisinger AJ, Lorimor RJ, Aday LA, et al: Terminally ill cancer patients: Their most important concerns. Cancer Pract 5:147-154, 1997.
2. McClement SE, Chochinov HM: Hope in advanced cancer patients. Eur J Cancer 44:1169-1174, 2008.