Although patients most often come to the physician looking for medical perspective on what can be done about their cancer, it is critical that physicians and other health-care professionals remember that unless we know what the patient’s goals are, our ideas and our plans of therapy may not address the patient’s needs. As a consequence, it is critical for the physician to ask the patient to share in setting treatment goals because it is the patient who must undergo the rigors of treatment and be willing to abide by its consequences. Whereas the physician’s medical recommendations most commonly are accepted, some patients reject them as inappropriate for a variety of reasons. Some ask the physician for another recommendation, and others seek the opinion of a second physician. The physician must clearly present the reasons for the treatment recommendations and why those recommendations seem to be the best ways to achieve the treatment objective. The physician has the obligation to make a treatment recommendation, but the patient always has the right to reject that advice without fear that the physician will be upset, dislike the patient, or refuse to continue to give the patient care.

Before a physician decides on a course of treatment to recommend for a patient with cancer, an achievable medical goal of treatment must be clearly defined. If the goal is to cure the patient of cancer, the strategy of therapy is likely to be different from the strategy chosen if the purpose is to prolong life or to relieve symptoms. To propose the goal of therapy, the physician must be:

Armed with this information and with the treatment goals in mind, the physician can develop a course of treatment and make a recommendation to the patient.

Components of the treatment plan include the following:

The oldest, most established, and still most effective way to cure most cancers is surgery. Surgery is selected as the treatment if the cancer is limited to one area and if it is anticipated that all cancer cells can be removed without unduly compromising vital structures. If it is believed that the patient can survive the operation and return to a worthwhile life, surgery is recommended. Surgery is not recommended if the risk of surgery is greater than the risk of the cancer; if metastasis always occurs despite complete removal of the primary tumor; or if the patient will be left so debilitated, disfigured, or otherwise impaired that although cured of cancer he or she feels that life is not worthwhile. If metastasis regularly (or always) occurs despite complete removal of the primary tumor, the benefits of removal of the gross tumor should be clearly defined before surgery is undertaken.

Most commonly, surgery is reserved for treatment of the primary neoplasm; at times it may be used effectively to remove isolated metastases (e.g., in lung, brain, or liver) with curative intent. Surgery is also used palliatively, such as for decompression of the brain in patients with glioma or biliary bypass in patients with carcinoma of the pancreas. In nearly all nonhematologic cancers, a surgeon should be consulted to determine the role of surgery in the optimal treatment of the patient.

Radiotherapy is used for the treatment of local or regional disease when surgery cannot completely remove the cancer or when it would unduly disrupt normal structures or functions. In the treatment of some cancers, radiotherapy is as effective as surgery for eradicating the tumor. In this circumstance, factors such as the anticipated side effects of the treatment, the expertise and experience of local oncologists, and the preference of the patient may influence the choice of treatment.

One determinant of the appropriateness of radiotherapy is the inherent sensitivity of the cancer to ionizing radiation. Some kinds of cancer (e.g., lymphomas and seminomas) are highly sensitive to radiotherapy. Other kinds (e.g., melanomas and sarcomas) tend to be less sensitive. Such considerations do not preclude the use of radiotherapy, however, and it is helpful to obtain the evaluation of the radiation oncologist before initiating treatment so that treatment planning can take into consideration the possible contribution of this modality.

Although radiotherapy is frequently used as the primary or curative mode of therapy, it is also well suited to palliative management of problems such as bone metastases, superior vena cava syndrome, and local nodal metastases.

As its primary role, chemotherapy treats disease that is no longer confined to anatomic one site or region and has spread systemically. In the earliest days of chemotherapy, this interpretation directed its use to diseases that regularly presented in a disseminated form (e.g., leukemia) or after disease recurred following primary management with surgery or radiotherapy. It is now understood that widespread systemic micrometastases commonly occur early in cancer. These metastases are associated with certain predictive factors such as the axillary node metastases of carcinoma of the breast and the large tumor size and poorly differentiated histologic features of sarcomas or the genetic profile of the cancer. Therefore, chemotherapy is now applied earlier to treat systemic disease. When this treatment is used for micrometastases, the response of an individual patient cannot be measured unless the chemotherapy is used as a neoadjuvant, that is, before surgery or radiotherapy. In that case, tumor response may predict more important endpoints such as time to treatment failure and survival. More commonly, when the chemotherapy is used as an adjuvant after removal of visible disease, the effectiveness of therapy must be determined by comparing the survival (or disease-free survival) of patients who receive therapy with that of similar (control) patients who do not receive therapy for the micrometastases. Chemotherapy also has a role in the treatment of localized or regional disease.