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April 2015

Losing “Losing the Battle With Cancer”

Author Affiliations
  • 1Department of Surgical Oncology and Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston
  • 2Deputy Editor, JAMA Oncology
  • 3Knight Cancer Institute, Portland, Oregon
  • 4SWOG Group Chair’s Office, Oregon Health and Science University, Portland
  • 5Fight Colorectal Cancer, Alexandria, Virginia
JAMA Oncol. 2015;1(1):13-14. doi:10.1001/jamaoncol.2014.188

Patients with cancer lose many things of importance. As soon as they hear the words “you have cancer,” they lose control over their lives, as medical appointments immediately begin to shape their daily schedules. They may lose the ability to participate in activities that bring them joy, as a result of chronic treatment adverse effects such as neuropathy, bowel issues, or lymphedema. Too many lose their lives. We also commonly hear the statement that a patient has lost “his or her battle” with cancer. As physicians who treat oncology patients, and as advocates, we believe that this quote is unsuitable and even demeaning to the patient, his or her family, and friends.

Since President Nixon declared a “War on Cancer” back in 1971, many have used some variant of the term battling cancer in describing all sorts of oncologic treatment, from undergoing locoregional therapies such as surgery and/or radiation therapy, to seeking systemic chemotherapies or biologic therapies, and even pursuing alternative regimens. This is particularly common in advertising campaigns for hospitals or oncology programs. Almost daily we experience some written or broadcast news story on a patient who lost his or her battle with cancer. There have been several outstanding and passionate editorials and comments on this topic, and a Google search on “lost the battle with cancer” can certainly supply some good reads. However, we wish to revisit this topic because there is the need to explain that receiving a diagnosis of cancer should not deny anyone their dignity; no one with cancer should be considered a “loser” in any way during the course of neoplastic disease, including those patients who die of their cancer, effects of their therapy, or by other legal choices such as physician-assisted suicide.

Using the battle metaphor implies that if a patient fights hard enough, smart enough, and/or long enough, he or she will be able to win the war. Unfortunately, and with rare exceptions, patients with metastatic cancer cannot conquer cancer (win the “war”) no matter how hard they fight. We have far too few effective curative treatments and interventions. We can celebrate occasional long-term survivors, but for the most part, we do not know why one person is alive 15 years after the diagnosis of advanced cancer, whereas another dies 9 months after the diagnosis. Patients with “curable” disease are cured because treatment eradicates every last cell, not because the patient did or did not somehow fight valiantly.

Moreover, patients do, of course, frequently die of cancer, but they are not losers in a battle. Once someone receives a cancer diagnosis, especially advanced-stage disease, a journey begins; sometimes the journey requires patience, tolerance, and courage, but at some point, most patients with advanced disease end that journey with loss of life. Although this difficult and tumultuous journey may have come to an end, dying should not be viewed as being defeated in some kind of skirmish.

Many patients themselves adopt the battle metaphor when they receive the diagnosis. If one needs to assume a warlike attitude to face the challenges of cancer, so be it; anything goes in helping a patient (and his or her family) cope during this journey. We have all had the experience of patients stating (paraphrased) “I want curative treatment, not palliative treatment, because I’m going to beat this thing.” The litany of imaging, appointments, examinations, blood sampling, pills, infusions, surgery, and radiation treatments can make a patient feel as if he or she has been in a fight. However, thinking about it from a different perspective, the use of the battle metaphor implies a level of control that patients simply do not have.

When is the last time you said that someone lost his or her fight with cardiac disease? Or with a car wreck? Or with a massive stroke? Patients in those situations have not lost a battle—they have died. The patient who dies of cancer, just like someone dying of cardiac failure, has simply died.

Additionally, when we talk about the “battle,” we minimize the real issues faced by patients every day. Patients deal with and sometimes overcome nausea, pain, fatigue, and weight loss. They suffer the isolation that comes with a diagnosis. For those with potential curative disease, they live with the fear of recurrence and impact of chronic adverse effects. Unless you have been in their shoes, it is often hard to imagine the challenges faced every day by our patients, and we oftentimes do not fully credit patients for their persistence and resilience in their journey. Let us recognize them for all the challenges that they overcame in their journey. Let us not declare them losers at the end of this journey. When a person runs a marathon, we credit them for their training, commitment, and aspirations. We never declare anyone from the second-place to last-place finishers in a marathon to be losers.

Similarly, the continuous urge to win the battle extends to oncologists, who actively treat patients for too long. The fact is that 8% of patients receive chemotherapy within 2 weeks of dying of cancer, and 62% within 2 months.1,2 Late chemotherapy is associated with decreased use of hospice, greater use of emergency interventions (including resuscitation), and increased risk of dying in an intensive care unit vs at home.3 This all clearly reflects our society’s need to battle until the end. But let us take a closer look at this mentality. Most of our therapies are toxic: they cause depression of the immune system, fatigue, rash, nausea, vomiting, neuropathy, and so forth. In addition, in today’s insurance landscape, many of our therapies can lead to financial toxicity. Patients are willing to deal with these adverse effects as a trade-off for “hope”—but are we honest with them about the true potential benefit of the treatment? For many therapies, there is little evidence that life is substantially prolonged (for argument’s sake, let us define “substantial” as 2 months or longer). We have seen patients who are determined to win their battle. As they turn from treatment to treatment, they are not spending time with loved ones; rather, they are chasing the illusive “win,” a path that affects not only them but also their family and caregivers, as well as family finances.

There are patients who face their mortality with clear eyes and, yes, courage. They make choices and can opt to die on their own terms: they can choose to die without a drug-induced rash, diarrhea, or fatigue. They may also choose to spend their remaining time doing what they wish, without an intravenous line or infusion port. They may choose not to be confined to weekly infusions and repeated blood sampling and imaging. In fact, a brave young woman with a brain tumor recently opted to complete a bucket list while feeling well; she then chose to die on her own terms under the Oregon Death With Dignity Act, establishing residency in that state after learning of her brain tumor and anticipating suffering in the later stages of this disease.4 Did she lose her battle? Or did she choose to control how she spent her final days? We would venture to say that she made an informed, reasoned decision to say “no more”—no more pain, no more marginal treatment, no more treatment-induced adverse effects: no more!

Of course, the choice to end one’s treatment and even one’s life (through the Death With Dignity Act) belongs with the patient. The patient’s decision is informed by their health, their family, their belief system, and, from a pragmatic point of view, their location. We firmly believe that health care professionals owe their patients the difficult and honest discussions that come as patients grapple with their mortality. We also believe that patients’ decisions should be honored and supported by their health care team.

Let us respect patients who are already suffering from the effects of cancer and cancer-related therapy. Recently, ESPN anchor Stuart Scott died of cancer at the age of 49: 7 years after his initial diagnosis and aggressive therapy. At the ESPY awards in July 2014, in the midst of enduring his cancer and therapy, Mr Scott told the audience, “When you die, it does not mean that you lose to cancer. You beat cancer by how you live, why you live, and in the manner in which you live.”5 We will all die one day; perhaps the winner here is the person who does it under his or her own terms; the person who dies peacefully and not at war. Let us focus on the life that people enjoyed before being told “you have cancer” and remember them as victors in life, not losers in death. Let us stop letting cancer appear to be the winner.

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Article Information

Corresponding Author: Lee M. Ellis, MD, Departments of Surgical Oncology and Molecular and Cellular Oncology, Unit 1484, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 (lellis@mdanderson.org).

Published Online: February 12, 2015. doi:10.1001/jamaoncol.2014.188.

Conflict of Interest Disclosures: Dr Ellis is an ad hoc consultant to Genentech/Roche, Eli Lilly, and Celgene. No other disclosures were reported.

Correction: This article was corrected online February 23, 2015, for typographical errors.

References
1.
Kao  S, Shafiq  J, Vardy  J, Adams  D.  Use of chemotherapy at end of life in oncology patients.  Ann Oncol. 2009;20(9):1555-1559.PubMedGoogle ScholarCrossref
2.
Greer  JA, Pirl  WF, Jackson  VA,  et al.  Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer.  J Clin Oncol. 2012;30(4):394-400.PubMedGoogle ScholarCrossref
3.
Wright  AA, Zhang  B, Keating  NL, Weeks  JC, Prigerson  HG.  Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study.  BMJ. 2014;348:g1219-g1229.PubMedGoogle ScholarCrossref
4.
Maynard  B.  My right to death with dignity at 29.CNN. Updated November 2, 2014. http://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/.
5.
Foss  M.  Hannah Storm breaks Stuart Scott's passing to the world in incredible eulogy. USA Today. January 4, 2015. http://ftw.usatoday.com/2015/01/stuart-scott-hannah-storm-espn-eulogy.
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    2 Comments for this article
    EXPAND ALL
    The Battle Against Unsuitable Medical Language
    (1) David B. Sykes, (2) Darren N. Nichols | (1) Massachusetts General Hospital Cancer Center (2) University of Alberta
    It was with great pleasure that we read Drs. Ellis, Blanke, and Roach’s recent Viewpoint “Losing ‘Losing the Battle with Cancer’” 1. The authors entreat us to avoid this “unsuitable and even demeaning” colloquialism. We agree with them; language matters. In our own recent manuscript, we speak to the importance of updating our medical lexicon, and in particular to discontinuing the use of the word ‘fail’ with colleagues and patients 2,3. No patient fails chemotherapy, rather it is the chemotherapy and our lack of perfectly targeted therapies that fail the patient. The true physician, the true healer, masters this aspect of patient care, empowering the dying patient and preparing for death with the recognition that a cancer death is so often the bad luck of a particular mutation and not the result of the patient’s unwillingness to continue the battle with cancer. Perhaps our linguistic duty is to replace the battle metaphor with language that honors those who move through suffering and face the end of life’s journey with equanimity and grace. When we conflate beating cancer (a noxious disease) with beating death (a natural step in life’s journey) we are doing our patients and our system a grave disservice. Language matters. The authors are correct: the right language can save health care resource, avoid futile treatment, and help our patients in the journey towards a dignified death.References1. Ellis LM, Blanke CD, Roach N. Losing “Losing the Battle With Cancer”. JAMA Oncology. 2015;1(1):13-14.2. Sykes, DB, Nichols, DN. There Is No Denying It, Our Medical Language Needs an Update. Journal of Graduate Medical Education. 2015;7(1):137-138. 3. Parles, K, Chabner, B. ‘‘The patient failed chemotherapy’’… an expunged phrase. Oncologist. 2004;9(6):719; author reply 719.
    CONFLICT OF INTEREST: None Reported
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    Re: Losing “Losing the Battle With Cancer”
    Carol Halberstadt, B.A. and graduate study | Person and patient living with cancer(s); Published in JAMA Poetry and Medicine; Newton, Massachusetts
    Yes, the language is pervasive, and it is deeply demeaning and insulting. There is no “war,” there is no “battle,” and there is no “losing” (or “winning”). There is illness and there is healing and there are short- and long-term side effects, and there is surviving and “survivorship”; there is suffering and pain, and there is life to be lived as well as it can be—and no one can predict or define exactly what that is, or what will be, because each patient, each person is unique and different, and at the end there is death, and before that there are all the other experiences that for me, as a poet, I’ve written about in the poems I‘ve been honored to have published since 2015 to 2019 in the Poetry and Medicine section in JAMA, among many others.

    Yet, despite your article almost 4 years ago, and the comment (below) that eloquently affirms that the “battle” language should be removed, it still appears regularly in the way people living (or dying) with cancers are described. There is no "courageous battle,” which is “lost” (or, if luck prevails, “won.”)

    I’m glad to see JAMA Oncology reissue this article.
    CONFLICT OF INTEREST: None Reported
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