As a member of the European Society for Medical Oncology, I attended the annual conference of the society held in Vienna in September this year. After the conference, I took the opportunity to have a short holiday in Prague and Budapest. Both Prague and Budapest are lovely cities, steep in European history and culture. I enjoyed the sights. I indulged in the local cuisine. I loved the autumn air. You, too, would undoubtedly have wonderful memories of holidays past.
We, oncologists, coined a rather dreamy term to describe the period in between intensive chemotherapy treatment episodes that patients with advanced cancers have to undergo: treatment holiday. In the treatment of advanced cancer, a total cure is, more often than not, unachievable. The more realistic aim is to control the cancer: hold it down, shrink it and prevent it from spreading further. The strategy of the old school of thought goes something like this: treat the patient with an intensive course of chemotherapy to achieve a remission and then stop and watch. Remission describes the partial or complete disappearance of the cancer after treatment.
Since advanced cancer is never completely cured and the root of the condition remains, the cancer inevitably reactivates after the cessation of treatment. When the cancer rears its ugly head once more, chemotherapy is restarted to try to suppress it again. Some patients do, in fact, take the opportunity when they are off treatment to go for a holiday. Cancers, unfortunately, do not “go on holidays”.
The trouble is this: When the cancer reactivates during the “treatment holiday”, the condition of some patients worsens rapidly and treatment cannot be restarted in time to arrest the growth of the cancer. The holiday turned out to be the last. The thinking of a new school of thought is gaining traction. After gaining successful control of the cancer through a period of intensive chemotherapy, I often switch gear to a lower intensity treatment to maintain the hold over the cancer rather than pause completely.
The length of time over which control can be maintained is variable, depending on the type of advanced cancer and the specific condition of the individual patient. “It’s like diabetes, I suppose. Nobody is ever cured of diabetes,” replied Mr K, a Chinese gentleman in his mid-sixties. I had just broken the news to Mr T. The series of tests he underwent confirmed that he suffered from advanced lung cancer.
As of today, advanced lung cancer remains an incurable condition. Mr T also suffered from diabetes for the last fifteen years. He took his diabetic tablets religiously every morning. Over the last three years, he had to inject himself with insulin twice a day to keep his blood sugar level under control. After learning that his condition of advanced cancer is incurable, Mr K drew the parallel with his pre-existing condition of diabetes. Advanced cancer and diabetes are both incurable.
Is it possible to convert the condition of advanced cancer to a condition like diabetes, a condition that, though incurable, can be kept under control to allow life to go on? This is what the concept of maintenance treatment hopes to do. As I do not have the ability to cure most forms of advanced cancer, I will have to attempt to do the next best thing: try and convert it to something like diabetes. While the period of control over advanced cancer is never as long as that of diabetes, every day gained is precious.
What of the holiday many patients look forward to? With newer generations of chemotherapy and targeted therapy that carry substantially lower side effects, there are now options of switching gear to gentler chemotherapy to maintain cancer control while preserving the quality of life. Where possible, patients would, preferably, not have to choose between maintaining cancer control and a holiday. Many of my patients do, in fact, go on holidays while still on treatment. I might suggest that they visit Prague and Budapest.
This article is written by Dr Wong Seng Weng, Medical Director and Consultant Specialist, Medical Oncology, The Cancer Centre, a Singapore Medical Group (SMG) Clinic.