One size does not fit all in cancer care

Article written by Nathaniel Wiest, M.D., Ph.D.

“What would you recommend for your mother?”

Patients and families often ask me this question in clinic. As a breast medical oncologist, one metric that many people use to evaluate my proposed treatment plans is whether I would do the same for my loved ones.

Let me set the scene.

Ruth* is a delightful 82-year-old-woman who comes to the breast oncology clinic. She is wearing hearing aids and a “Cool Grandma Club” sweater. She was recently diagnosed with breast cancer after she felt a lump and has not started any treatments yet. She also has several serious health conditions. Most of all, she does not want surgery because she is worried she will not survive an operation.

“Mom, you’ve got to listen to the doctor” her daughter tells her.

She looks at me warily.

Let me set another scene.

This time, I am seeing Krystle*, a vibrant 44-year-old woman with two young kids. She calls herself a “Tiger Mom”. She had a mass discovered on her mammogram and underwent surgery to remove breast cancer. She has otherwise excellent health. I offer antiestrogen therapy to reduce the risk of breast cancer coming back.

“I don’t want antiestrogen pills,” she says. I dive into statistics, graphs, and studies to explain why I am offering the pills.

Oncology, like all of medicine, is both science and art.

On the scientific front, we have an expanding body of literature and clinical trials that provide treatment options. The number of pills, injections, lab tests, procedures, and treatment approaches continues to grow.

On the art and humanities side, four fundamental principles guide the actions of providers in medicine. First, to do good (beneficence). Second, to not do harm (nonmaleficence). Third, to respect an individual’s right to decide (autonomy). And forth, to treat people fairly (justice).

My job as an oncologist is to use these principles to empower each patient in their cancer journey with accurate information, available treatment options, and a care plan that reflects what matters most to them.

What can this look like?

First, let us head back to Ruth. She tells me, “I still have things left on my bucket list” and that she does want treatment— just not surgery. After reviewing all her options, including not treating, she chooses to take antiestrogen pills only. This plan is unlikely to cure her cancer, but it will likely control it for some time. “That’s all I need,” she says with a nod and a smile. Most importantly, it avoids surgery, which matters most to her.

Next, let’s revisit Krystle. I show her studies and graphs and cite statistics for how the antiestrogen pills reduce the risk of cancer coming back. I explain how the pills can improve the chance she will be alive and breast cancer-free in the future. I discuss possible side effects of different options and ways to manage these. I use teach-back— a method where you ask the person to recite back the shared information to ensure understanding— which she does flawlessly.

The verdict? “I still don’t want the pills” she says. For her, the possible effect on quality of life outweighs the expected benefit. So, we make a different plan: close follow-up, careful monitoring, and regular visits. I also leave the door open to revisit treatment decisions later, which she agrees to.

Both patients made thoughtful decisions. Their choices were different, but each choice reflected what mattered most to them. Although both individuals in these examples were navigating breast cancer, the message of tailored treatment plans that fit each patient’s unique experience, values, and preferences extends to patients facing all types of cancer.

The principle of autonomy respects the intrinsic value of each person and their right to decide.

As I tell my patients, at the end of the day, the right decision is the one a well-informed patient makes that aligns with their values. Sometimes this is an elderly patient choosing a noncurative pill to avoid potentially curative surgery. Sometimes it is the mom with young kids who decides not to take antiestrogen pills because, to her, the risk of side effects outweighs the possible benefits.

If you or someone you love is facing cancer, try to be honest about what matters most. Ask questions. Listen carefully to provided options. Ask about the goals of treatment, the possible benefits, the potential side effects, ways to manage side effects, and how treatment may affect your daily life. Your medical team should help you understand the choices and support you in finding a plan that fits your goals and needs.

One size does not fit all.

Working together, we can find the right plan for each patient. It is not always easy work, but it is rewarding. Just like art, and just like science.

* Fictional patient based on real patient experiences

Learn more

• Read an article on purposeful shared decision making in medicine from the Mayo Clinic News Network.
• Learn about resources for cancer patients at Mayo Clinic.
• Join the Cancer Support Group on Mayo Clinic Connect, an online community moderated by Mayo Clinic for patients and caregivers.

Is there a topic you would like to read about on the Cancer Center Blog? Let us know in the comments or email our team at canceredcenter@mayo.edu.