Interesting double question, the first is "sort of easy"! Palliative and curative are the same as they were 20 years ago however the caveat is the "population" is now the major difference having changed their understanding (whether it be right or wrong) considerably.

The second question is a heck of a lot harder to answer as you are touching on the moral question of when treatment (rather than care) is no longer ethical.

However I don't believe that it is a simple black and white answer.

The access to information (as I said whether it is right or wrong) has meant that patients do expect more and often will sub-consciously not hear what a doctor may be saying. They will also be able to quote anecdotal evidence that proves a particular treatment works. We (patients and to some extent carers) also err towards the gambling side of our nature and whilst the population statistics may say a 95% failure rate, to a person who has been told they have the big C that 5% is pretty damn good odds and worth the risks especially when the other choice is death! It is difficult to know how much of the treatment is driven by the desires of the patient over the advice of the clinician, maybe I will leave that question to the clinicians on the list.

I will here argue that a new perspective and therapeutic posture towards metastatic disease is long overdue and that clinicians and medical researchers alike (including myself) need to be more circumspect in too quickly continuing to reject curative intent in metastatic disease.

So, surgery of lung metastases of almost all solid tumors is reported to provide good long-term results with 22% of patients still alive even after 15 years, and as  Ugo Pastorino writing for The International Registry of Lung Metastases in analyzing long-term prognosis in over 5000 cases of lung metastasis treated by lung metastasectomy (surgical removal of pulmonary metastases) concludes, "metastatic surgery represents a curative approach in almost one quarter of patients" with good prognostic factors (limited, or even more favorably, solitary, lung metastatic tumors, or multiple tumors at a single site, among many others). 

And a more recent International Registry of Lung Metastases found that based on the favorable risk factors (disease-free interval, number of metastases and complete resection, and in breast cancer, a hormone-positive tumor biology), the group with the best prognosis showed 5-year survival of 50%, with a median survival of near-six years, with outliers to 15 years and further.  The possibility of curative therapy becomes higher with the addition of a multimodal approach that includes chemotherapy, as recently found by Godehard Friedel writing on behalf of the International Registry of Lung Metastases (2002), the study with the largest documented number of resected lung metastases from breast cancer; the latest Registry concluded that "In our opinion . . . the statement that a curative approach is not possible in lung metastases from breast cancer is not tenable". 

This sentiment was echoed in the International Guidelines for Management of Metastatic Breast Cancer, on the topic of "Can Metastatic Breast Cancer Be Cured?" (the answer was yes for certain breast cancer patient populations) conducted by The European School of Oncology–Metastatic Breast Cancer / ESO–MBC Task Force (JNCI 2010); here we are using the mature definition of curative intent: “cure” doesn't necessarily mean destroying every cancer cell, but rather rendering the disease harmless, that is, without clinically significant adverse effects, for prolonged periods, as defined by the great Eva Singletary at MD Anderson in her now seminal paper "A Role for Curative Surgery in the Treatment of Selected Patients with Metastatic Breast Cancer", via a "curative, multidisciplinary therapeutic approach for at least a fraction of patients with limited MBC". 

This has culminated in the statement issued this January 2010 by the ESO–MBC Task Force that "Based on the available data, the ESO–MBC Task Force retains its original recommendation statement: A small but very important subset of MBC patients . . . can achieve complete remission and a long survival. A more aggressive and multidisciplinary approach should be considered for these selected patients." [Fatima Cardoso at the Jules Bordet Institute on behalf of the ESO–MBC Task Force (JNCI 2010)].

This has been further argued and reinforced by Gabriel Hortobagyi at MD  Anderson who recently concluded that "some patients who achieve a complete remission after chemotherapy remain in this state for prolonged periods of time, with some even beyond 20 years . . . and this finding challenges the commonly held belief that metastatic breast cancer is universally fatal."  Furthermore, in pooling MD Anderson and University of Colorado survival data for MBC patients, it was found that "5 years after regional treatment of a recurrent or metastatic lesion, 36% to 52% of patients remain not only alive but without evidence of metastatic disease.  This is remarkable, because it is contrary to all other experience in metastatic breast cancer" and that "These reports show that 3% to 30% of selected patients with biopsy-proven distant metastases from breast cancer and who can be rendered disease-free with multidisciplinary treatments are probably curable.", and thus, although prospective confirmation is still needed for dispositive status, we have appreciable "evidence in support of the hypothesis that metastatic breast cancer might be curable with a multidisciplinary approach".  Clinically, the implication in practice is that "First, it would suggest that a selected subset of patients with metastatic breast cancer should be approached with curative, not palliative, intent." 

In this connection, Ottavio Rena and colleagues in Italy found that resection of epithelial lung metastases (including from breast cancer) yields an acceptable favorable prognostic result in appropriately selected patients with very low perioperative morbidity and mortality, and that factors such as high disease-free interval, single metastasis and completeness of resection are demonstrated and confirmed to be significantly associated with long-term survival (Eur J Cardiothorac Surg 2006).  And, as noted above, chemotherapy and endocrine (hormonal)  therapy can add positively to prognostic outcome: so for example, the main prognostic factor seen in a small cohort of patients with histologically proven pulmonary metastases from breast cancer in the retrospective analysis conducted by Stefan Welter and colleagues in Germany was estrogen receptor status, with a 5-year survival for receptor positive patients of 76% (Eur J Cardiothorac Surg 2008). 

Stefan Gluck at the  Sylvester Comprehensive Cancer Center in Miami, Florida has just published an inspiring case of a 93-year-old woman who was diagnosed with stage I endocrine (ER+/PR+) T2N0M0 breast cancer at the age of 45, then diagnosed 22 years later with metastatic breast cancer (MBC) to the lung, followed by both bone and liver metastases.  She survived for 18 years  with metastatic lung, bone and liver disease, maintaining a good quality of life (QOL) and remaining mobile (with the help of a cane and walker due  to stroke), but in general asymptomatic.

This patient was stable on tamoxifen and then anastrozole (Arimidex) for a total of 12 years, with anastrozole (Arimidex) later changed to exemestane (Aromasin) for another 2 years.  Bone metastasis developed 36 years after initial diagnosis, for which she was treated with fulvestrant (Faslodex) and zoledronic acid (Zometa), and then switched to letrozole (Femara).  Then liver metastasis was diagnosed 38 years post-Dx, for which she was treated with full-dose capecitabine (Xeloda) monotherapy, discontinued at patient request due to grade 2 HFS (hand-foot syndrome), dying 2 years later.

What  is most remarkable is that with multiple visceral metastases (pulmonary, bone, and liver metastases), this patient lived for 18 years with metastatic disease to three sites (two visceral (lung and liver), and in bone) with acceptable QoL, and maintained largely on endocrine only therapy, with chemotherapy only introduced briefly towards end of her treatment. 

Increasingly, such cases are not unique: Naruto Taira and colleagues at the  National Shikoku Cancer Center in Japan presented a case study of a patient with metastatic breast cancer with pulmonary metastasis who maintained complete remission (NED) for ~10 years (on S-1, a prodrug of 5-FU), while Huang and colleagues at McGill University (Canada) presented a case of a 41-year-old BRCA2 breast cancer patient with lymph node recurrence and bone metastasis who achieved complete remission (NED) for 11 years (Tx with high-dose anthracycline-based chemotherapy followed by autologous bone marrow transplantation).

And there are several case reports of long-term survival with liver mets: Renata Zaucha at the Medical University of Gdansk reported the case of a 66-year-old hormone positive breast cancer patient with multiple liver metastases who survived and  remained active at least 11 years (as of last report) free of  all breast and visceral disease (after progressing on FEC, she was switched to MPA (medroxyprogesterone acetate) monotherapy which eradicated all cancer disease; while in addition Yoshio Naomoto and colleagues at Okayama University Medical School in Japan presented the case of a 39-year-old woman diagnosed with multiple liver metastasis plus liver dysfunction from breast cancer who survived 8 years with complete remission (treated with chemoendocrine therapy).

Nor should it be assumed that long-term survival from metastatic disease is solely the purview of recent advances in oncotherapy: we have cases of patients sustaining durable prolonged complete remission after chemotherapy, even out to beyond 20 years, as documented in the early EORTC retrospective review (Tomiak et al., Eur J Cancer 1996) and the MD Anderson series reported that same year (Greenberg et al., J Clin Oncol, 1996). Another MD Anderson series (Holmes et al., Breast Dis, 1994) of oligometastatic disease with 32 of 136 MBC patients surviving beyond 15 years, and amazingly in a later follow-up at 26 years (!), just 2 events were observed after the 15 year point in these (n=32) patients, indicating remarkable durability of remission and maintenance of QoL. Even more important, other data at the same institution (Holmes et al. Breast Disease 1994; and Rivera et al. Breast J 2002) were confirmative and expanded to 231 patients the group of patients with stage IV NED. And both the just reported MD Anderson data and that of University of Colorado Health Sciences Center on 60 assessable MBC patients (Nieto et al., J Clin Oncol 2002) demonstrate that 5 years after regional treatment of recurrent or metastatic disease, 36% - 52% of patients are both alive and without evidence of metastatic disease, vastly beyond the typical norms at this point.

Indeed, the aggregate of all this data I have compiled and cited shows that with multidisciplinary treatments as much as 30% of selected MBC patients can be rendered disease-free and hence effectively if not strictly curable, namely as I define it, exhibiting a high degree of durable long-term remission as disease-free response, several manifolds above the typical norms and with high QoL, especially in - but not wholly restricted to - patients with limited / oligometastatic disease. Even with late relapses not uncommon in endocrine-positive breast cancer, nonetheless a significant subset has achieved effective cure. And as David Bartlett's team at University of Pittsburgh has shown in answer to the query "Can metastatic colorectal cancer be cured?", this evidence of effective cure in metastatic disease is in no way confined to breast cancer alone and includes colorectal, lung, prostate, melanoma, and several other malignancies.

A New Vista

These and many other known cases demonstrate that long-term remission, if not (technically) cure, is achievable in the context of metastatic breast cancer, and that in addition, long-term survival with stable metastatic disease is also achievable, allowing for durable and extended prolongation of life with acceptable QoL, even with multiple metastases to lung, liver and bone.     

Thus, increasingly, expert attitudes have changed concerning the curability of metastatic disease and fewer clinical leaders accept the naïve view that patients with metastatic disease invariably die from it, but rather recognize the divergence of this unnuanced view from clinical reality in the fields, therefore marching along with the great Neil Rosen at Memorial Sloan-Kettering Cancer Center who recently at the Controversies in Breast Cancer conference I attended observed radically – but no longer a lonely voice - that he believes in curing metastatic disease (as I do myself in many tightly defined circumstances).  For we now know, from the long-term follow-up series at MD Anderson along with other accumulated data that:

1. many patients will die with their disease, but not from their disease;

2. some will not even die with their disease (see below);

3. still others are currently long-term survivors whose ultimate fate is unknown, but therefore not assured to be from breast cancer mortality

4. still others who are predominantly stable, or at least what I call controlled-progressive - with some degree of progression (sometimes with other tumors in remediation) that can be significantly regressed upon each progression - are, on the odds, highly likely to benefit from what I call the time value of survival: namely, that outcome odds can be improved with each year of additional survival by virtue of the advance of research and clinical developments.

So in this vein, Kathy Miller at Indiana University recently commented on these findings, observing that there is always known to be a "group of patients [who] are potentially cured of their metastatic disease".  And the great Gabriel Hortobagyi at MD Anderson, one of the principal collectors of the long-term survival repository, has stated as long ago as 2001: "I also believe that you can cure some patients with metastatic breast cancer" and, based on that data, that for some metastatic disease patients "we can achieve a complete remission". He expands on this widely misunderstood phenomenon: "My group has published about patients who have achieved a complete remission with chemotherapy and are in a progression-free complete remission 20 years later — biopsy proven" and that "for instance, I [Dr. Hortobagyi] have a patient who had a lung metastasis resected in 1968, and she never received any additional therapy. She never had a second metastasis — metastatic breast cancer by definition, pathology proven, and she’s alive and well — 32 years of disease-free survival."

This is not news to clinicians and researchers who deal extensively with advanced disease, as I do.  I know, across numerous countries, many 15, and 20+ year and a few 25+ year survivors of metastatic disease.  As I observed in my Paths of Hope series in another forum [No Surrender Breast Cancer Foundation], I even am acquainted with of long-term survivors of CNS (brain and/or leptomeningeal) malignancies and of multi-site TNBC disease. In many cases I have advocated and advised patients to consider long-term maintenance of metastatic disease with metronomic therapy, among others thus enhancing the potential for durable disease control while dramatically minimizing toxicity and harm to the patient, and sustaining high QoL.

Finally we may have to remember increasingly that the outliers - the exceptional group of long-term survivors - of today may be the norm of tomorrow, and we have arrived at the confirmed reachability of effective cure for metastatic disease.

Constantine Kaniklidis

Director of Medical Research,

No Surrender Breast Cancer Foundation (NSBCF)

European Association for Cancer Research (EACR)

I find this to be a very interesting question and one in which is more commonly misunderstood in today's healthcare environment. Many hospitals have implemented Pallative Care teams as an added support for those patients faced with serious medical conditions. The term pallative care is often confused with hospice care.

Palliative care is for a person of any age, whether or not his or her illness is terminal. Today, palliative care can help anyone who has a serious illness. For example, one may want palliative care while getting treatment for heart failure. Palliative care can help the patient manage symptoms or side effects of treatment by providing the patient with tools and support to better understand and make choices in regards to the plan of care for his or her illness.

Hospice care is a type of palliative care for people who are in their final weeks or months of life.

With palliative care, there is a focus on relieving pain and other troubling symptoms and meeting one's emotional, spiritual, and practical needs. In short, this new medical specialty aims to improve one's quality of life -- however the patient define that for him/herself.

One of the strengths of palliative care is recognition of the human side of illness. In a 2011 survey of palliative care patients, they mentioned these particular needs: "being recognized as a person," "having a choice and being in control," "being connected to family and the world outside," "being spiritually connected," and "physical comfort."

The purpose of Palliative care is to provide the patient with a voice and a sense of empowerment over his or her own illness.

Does palliative care mean that you're dying? Not necessarily. It's true that palliative care does serve many people with life-threatening or terminal illnesses. But some people are cured and no longer need palliative care. Others move in and out of palliative care, as needed.

Palliative care can be regarded as a type of curative therapy in my opinion. Death is something we as humans will all face at some point. For those patients living with chronic illness palliative care can help provide patients with the tools they need to have better quality of life without the focus on quantity.

Ahhh an Interesting addition by Aimee, which of course leads us down the path of the small issue as to how we define palliative. So to make the somewhat murky water clearer it is pretty easy for me as I refer to http://www.health.gov.au/palliativecare for my definition and hence the starting point of my comments. However that approach would ignore the addition by Constantine. I guess it is a bit like saying "yes the application is dicom compliant", but let's not get side tracked!

So I guess we actually need Hans-Guenter to give us his definition of "Palliative" and possibly restart the conversation as clearly there are differences.

I am interested in Constantine's addition as I guess it does lead us more towards always taking a more "aggressive" approach to treatments so we don't "miss" the outlier.

Where do we go from here.

I agree with Aimee. It's so important from a patient point of view that we don't send the wrong messages. There are a lot of cancer patients are probably never going to be cured, but will live maybe for several years with their cancer, probably having some palliative input along the way, but also often having some quite aggressive treatment, particularly at the beginning. Say "Palliative" to them, and many instantly think, "Help, does that mean I've only got a few months to live"? The term "palliative" has become incorrectly associated with "terminal", and we need to deal with that.

I think it's important to involve the patient in decision making process mainly using the institutional data to support the recommendation of any complex/mutilating surgical procedures. Counselling must include quality of life issues and potential frequent and long-term complications. Adequate timing and support is also necessary for the actual decision process !. We should consider any of the mutilation e.g. total pelvic and vulval exenteration, as " palliative" but if all margins are clear of tumour this may be potentially curative with other quality of life issues.

Prolonging life vs palliation need to be discussed in multi-disciplinary settings prior to counsel or undertaking any of these procedures.

Hmmmm.......... so once again terminology appears to the the bane of this discussion. If we consider this from a logical standpoint and apply an "avoid the wrong message" approach then equally we would also refrain from the use of the word curative. So how then do we describe the treatment? Does all treatment now become just a game of quoting statistics...... some good....... some bad? Are we doing our patients a better service by simply not distinguishing between treatment delivered with palliative or radical/curative intent? I would certainly be interested in what thoughts Hans-Guenter has on this current conversation, hint, hint a response please!!!

Maybe it would be better that we take some lead in terminology use from http://guidance.nice.org.uk/CSGSP/Guidance/pdf/English. The use of the term supportive care simply puts a patient onto a treatment pathway and whether they may or may not eventually follow the palliative care path (which eventually leads to terminal care) depends on their disease and its progression. Whilst the document isn't the easiest to digest, R.Thomas & A.Richardson do provide a somewhat easier summary read in their paper http://www.sciencedirect.com/science/article/pii/S0936655504001815.

Now, I am able to be back to the discussion of the question I posted. I have to apologize many times, but because of a software problem I was only able to write a few words and then the laptop was frozen and I was not able to complete the answer. But I prepared something:

@ first comment of Lindsay Thremethick: You are right and I strongly believe that there is no simple black or white answer. Many informations patients receive from physicians are confusing and controversial and this without any evidence. But if we believe in and practice 'evidence-based medicine' this shold not happen any more. Every patient should have the possibility to chose his/her risk of treatment or 'not-treatment'! Every physcian should be able to communicate the pros and cons of the therapy to patients, that they are able to understand. But in these decisions there is not a chance to win or lose as you mentioned (this would be black or white) but in many cancer patients or in other sever chronic diseases you will have the chance to live longer , but with different qualities of live. Two weeks ago, a lady was sent to me with peritoneal carcinomatosis of colorectal origin to evaluate cytoreductive surgery and HIPEC. After evaluation of the patients history, the CT-scans, her physical state etc. she would have a real chance to have benefited from treatment. But after 48 hours she told me, that she decided to have systemic chemotherapy as her treatment of choice. According to the observations, experiences and studies published of care-givers of this special treatment, systemic chemotherapy has a worse outcome than cytoreductive surgery and HIPEC considering life expectancy ('8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer.'; http://www.ncbi.nlm.nih.gov/pubmed/18521686?dopt=Abstract)

Her argument was, that she wanted to preserve her quality of life, she had at this moment as long as possible despite a shorter life expectancy.

@ Constantine Kaniklidis: You made some important remarks! All the cases and all the registry reviews you mentioned aim at patient selection! This is the key to the solution of the question - as I think. You can do the right therapy, follow all the gguidelines, have best evidence, but the patient who is in the center of all our efforts will not have benefit. To visualize this, if you have patients with metastatic disease, you are right dependant from primary tumor up to 30 % might have the chance of cure despite their UICC IV status. But the other way round 70 % have not this chance, but in cancer treatment they will have the side-effects of our treatment! And these side-effects can be very important to patients, if you think about loss of organs, creation of ostomy procedures, loss of sexual functions, loss of speech or body-shape; but in medical oncology they are not less if you consider hand and foot syndrome or severe polyneuropathy as sequelae of chemotherapy or the modern biologicals. You are right, I know patients too, that have/had a high quality of life despite their metastasizing cancers and lived years after their diagnosis of peritoneal spread or other metatases (bone, liver, lung etc.). But many of these patients were often mor and with higher quality informed about their diseas and prognosis than many physicians! We can help these patients to maintain their quality of life with our treatment like metronomic chemotherapy or some operations removing some metastases! But if we aim at cure in these patients by doing radical surgery, we will destroy their quality of life!

@ Aimee Buchanan: You are right with your definition of palliative care! 'Palliative' is derived fromthe Latin 'pallium' (coat). It means, that you try to hide the symptoms of the disease, to relieve pain or thurst. If you look at dictionaries it is the only word, that has a defintion. The word 'curative' is not well defined - and that is a problem. You can use it as in treatment of a fracture of the wrist. After treatment every symptoms can be abandoned and the function is fully restored (I know this is the ideal!). But in cancer treatment, we need a more precise definiton I think. Is curative treatment only if after treatment their is life-long this kind of cancer abandoned? Or does it mean, we are able to control the patients disease, so he/she can life for years with more or less treatment or cancer symptoms?

@Ailsa Ratcliffe: Your comment clearly demonstrates this problem: the shifting of the message transported. Palliative is not living short with bad quality of life. But with more and more aggressive treatment options this is the message transported to patients!

@ Pubudu Panthiraja: Decision making using all the tools we were trained to use, once! This is one key to solve the problems. But many care-givers ar not able to understand the interpretation of data and statistics - as it is demonstrated by G. Gigerenzer/ J.A Muir Gray: Better Doctors, Better Patients, Better Decisions: Envisioning Health Care 2020 (Strungmann Forum Reports). In this forum report the process of interpreting scientific data and statistics is demonstrated -together with the lack of our knowledge. It is very improtant to consider these thesis and to integrate tem into our daily practice.

But I have another remark to this question I posted long time ago: the question of acting 'honestly'. I will give an example. In my daily practice, I often hear and see colleagues talking with patients about their prognosis or about the results of cancer operations. If we really want informed consent with patients we should tell the truth!

I think my question has a lot of different aspects. It is not simple - even if it seems to be. And I think we should go ahead trying to define better the aims of our treatment with exact defined terminology.

Dear Hans-Guenter:

Thanks for your thoughtful commentary, about much of which we are in agreement. I will therefore only provide some qualifications and clarifications here of my position, and some modest difference in focus if not in opinion:

(1) With a typical target (met in vast majority of my patient/consults across above a dozen different malignancies) of 60 - 80% CBR/clinical benefit rate (complete response (CR), partial response (PR, at least 50% tumor volume reduction) and durable stable disease (SD), we can indeed as ESMO, St. Gallen and other evidence-based guidelines promote, treat the clear preponderance of advanced disease patients with curative intent whose goal as I was wont to explain is long-term survival with patient-assessed acceptable QoL, not - necessarily - disease eradication (note the requirement: patient-assessed QoL, not just observer (clinician) assessed QoL).

(2) I said nothing - and neither did ESMO, St. Gallen and other guideline authorities, nor the hundreds of oncologists I have interviewed over the last decade on this matter, some of which I quoted - about cure: I and these formidable authorities advocate acknowledging the therapeutic posture of curative intent as opposed to palliative intent, towards the goal of the maximal prolongation of life with patient-acceptable QoL.

(3) I did not address the issue of radical surgery at all in my commentary, but the evidence supports that there is no necessary and inevitable unacceptable compromise to QoL (as witness brain tumor resection and numerous others, all of course subject to refined selection procedures).

Nor, let me note, is the performance status of the patient always the determinative factor in electing curative intent; I will use one example I am personally involved in: the NCIC CTG trial the addition of the EGFR inhibitor erlotinib to standard gemcitabine therapy exhibited a significant, but small, benefit in median overall survival of 2 weeks in advanced pancreatic cancer, and this has led many clinicians to bypass such a combination biochemotherapy regimen out of the perspective that although statistically significant, is such a slight benefit of clinical relevance.

But I often advise this erlotinib + gemcitabine regimen. Why, given a 2 week benefit? What is being frequently missed is that if and only if, as the subgroup analysis demonstrated, a patient presents with a Grade II or higher skin rash (and which I can wholly manage to levels consonant with patient tolerability) as adverse event to erlotinib - regardless of performance status and other selection criteria - then we obtain a prolonged median overall survival of almost one year (10.5 months, with outliers further), a remarkable outcome in advanced pancreatic cancer (and by deploying strictly evidence-based integrative oncology with highly selective high level evidenced CAM (complimentary and alternative medicine) components, I can achieve durable long-term survival (years) even in this most challenging malignancy type). This and dozens of other examples I could provide demonstrate that it is not necessarily the higher performance status patients would benefit from treatment with curative intent, and in addition the increasing refinement of numerous prognostic and predictive markers associated with improved outcomes has made it possible to provide individual genomic profiling as an adjunct to such decision making.

In agreement with your observations, as clinicians we must candidly, with brutal honesty that every patient deserves, assess the real metrics of disease-free versus recurrence-free versus progression-free versus overall survival, each weighted by a frank determination of probable patient-specific (not just global) QoL (see below), along with Level I based (from SR, MA or Phase III RCTs) both absolute and relative risk, recurrence, and metastasis reduction metrics.

Here we all have the responsibility of the determination of and clear and honest presentation of:

(1) individualized QoL metrics like:

- the validated SEIQoL (Schedule for the Evaluation of Individual Quality of Life or SEIQoL–DW (Direct Weighting), or

- the QWB-SA (the Quality of Well-Being Scale) from HMRG (the Health Measurement Research Group), or

- others of near-comparable validation (FACIT, RSCL, SDS) to these well-validated preference-weighted measures of health-related quality of life,

in association with:

(2) the relevant disease-specific EORTC QLC quality-of-life questionnaires such as

- EORTC QLQ-BR23 for breast cancer,

- EORTC QLQ-LC13 for lung cancer,

- EORTC QLQ-BM22 for bone metastasis, and other malignancy-specific QoL metrics,

along with also:

(3) a caregiver-oriented QoL metric like CarGOQoL (CareGiver Oncology Quality of Life questionnaire, thus not leaving out a critical ingredient of oncological survival and QoL, the Caregiver.

In this way we can recognize the potential of treatment with curative intent, today, for many patients who would have been presumed only to warrant palliative intent in the past, and as oncologic science advances, as it is doing, to new levels of clinically relevant prolongation of life with, and wholly subject to, patient-assessed and patient-cognizant personalized

- to the individual, to the disease, and to the patient's articulated domains of retention of acceptable QoL (as spouses, as parents, as workers in specific professions requiring different degrees of retained ability, and even as persons of faith with deeply individual spiritual convictions affecting concerns of QoL and even the very prolongation of life) -

the palliative intent / curative intent boundary line will continue to shift, with dynamically apportioned roles to these categories reflective of the latest outcome benefits from the best of oncologic science.

What I read in your responses, Hans-Guenter, is the same - and unfortunately rare - commitment to a humanistic, not blindly mechanistic, oncology of care with life-concerns at the center, not at the periphery as has often been in the case until now. In that, we are both colleagues, and comrades-in-arms!

Constantine Kaniklidis

Director of Medical Research,

No Surrender Breast Cancer Foundation (NSBCF)

European Association for Cancer Research (EACR)

Welcome back Hans-Guenter, I was starting to wonder whether you had just lobbed this 'grenade' into the room and just 'waiting for the dust to settle' ...... however it seems it was a case of "but to really foul things up you need a computer". Having said that my response here is somewhat tardy and also computer related issues.... "too many emails"..... I completely missed you response.

The palliative-curative boundary is a very interesting discussion and I think that whilst we continue to think populations and statistics that is as sophisticated as we can achieve. However when we begin to think Personalised Cancer Medicine (PCM) then we do find that the existing population/statistics paradigm very lacking but equally so is our broad understanding of PCM. I think it is reasonably fair to say that PCM, whilst it has been our ultimate goal for a very long time, we are still in a state of development rather than completely mainstream. I know there have been conferences/seminars dedicated to PCM for several years but unfortunately it really hasn't spread to every facility as standard practice. However there are fortunately many proponents who are dedicated to advancing PCM as the standard practice. I can see PCM as being a double edged sword for the clinician. When we begin to know more about the patient and their cancer we will better understand their true prognosis which will unfortunately result in the unenviable responsibility of passing on this information to the patient when the information is bad because our PCM isn't sophisticated enough to deal with their particular cancer expression.

Clearly your question has prompted great discussion that has illustrated just how poorly palliative/curative is either understood or utilised, I think the NHS has, to an extent, begun to address this with the concept of supportive care but maybe we are not quite there yet.

Well, I think Personnalised Cancer Medicine will have benefits for patients. The way to this medicine is extremely long, because we have a lot of obstacles to overcome! We need better training in decision making, ethics and in communication skills to provide personalised cancer medicine. Some may ask "why?". It is because many health care providers permit not patients to participate in decision making processes - as it should be. And the decision making process is influenced by lots of other interests like hospital reimbursement, figures of e.g. colorectal resections or hepatic resections because the department needs some figures. This is a really sad development and it is dangerous for patients!

We need to be more honest to our patients about their expectations and their prognosis. We have lots of markers, today - some of them have therapeutic implications like KRAS mutation in colorectal cancer, some have only prognostic implications like BRAF in UICC IV colorectal cancer. So we need to communicate these informations to our patients and therefore we need better ethical background and communication skills - on the other way we will act as Dr. HODAD (= Hands of Death And Destruction as he is described by M. Makary: "Unaccountable").

I think it is difficult to use the terms 'palliative' or 'curative' nowadays, because these terms are ill-defined as shows this discussion. I would propose the terms 'treatable' ( that comprises surgery, radiotherapy, chemotherapy, biologicals etc. and aims at disease control > 6 months) and "best supportive care" ( relieving symptoms). On either way there should be a ful participation of the patient.