doctor talking to patient (448 x 299)

At some point in his or her career, every practicing oncologist has been asked this difficult question by a patient:  Doctor, how long do I have to live? I’ve been asked that question hundreds of times. Sometimes the question about the patient’s survival comes from family members.

Because we’ve spent our early medical careers learning the life expectancy associated with specific cancers, our impulse is to give patients and their family members an answer. Although we may be aware of the average life expectancy for an individual with a certain disease, in my experience, those statistics did not apply to my patients. Of course, all patients hope that they will be cured of their cancer, or if that’s not possible, they at least hope to have a high quality of life for as long as they can.

I once had a patient who taught me about the importance of hope. His name was Jack and he had gastric cancer with liver metastases. Jack and I discussed the fact that there was no cure for his disease, and he said that he hoped for some quality time before the cancer progressed.


Not-So-Silly Question

I started Jack on a regimen of chemotherapy, and after just two courses of treatment, he achieved a remarkable 70% shrinkage of the tumors in his liver, which resulted in a significant improvement in the quality of his life.  At a follow-up office visit, I asked Jack if he had any questions about his prognosis.  He thought about it for a moment and then said, No, doc, I’m very pleased with the result.

As I opened the office door, Jack said, There is one question I’d like to ask, although it may seem silly. I said, Go ahead and ask your question. My subscription to Time magazine has run out, Jack said. If I buy a copy at the newsstand it will cost me $2 per issue, but if I get a 6-month subscription, I can save $8. What do you think I should do? I looked at Jack, smiled, and said, I know you will save a lot more money if you get a 1-year or even a 2-year subscription. No one knows how long any of us is going to live but if it were me, I would get a long-term subscription to the magazine. Jack’s face beamed with delight. Thanks, doc, that’s great to hear, he said.

As I left the exam room, I thought about the power of hope.  I had given Jack hope.  We had never discussed how long he had to live, but I had given him something to look forward to, and that was all he needed to hear.


Predicting Survival

During my long career in medicine, I have seen many incurable malignancies, such as testicular cancer and some forms of leukemia, lymphoma, and breast cancer, become curable or at least treatable diseases. Who was I to presume to know how long Jack, or any of my patients, would live? The longer I practiced medicine, the more I came to believe that neither I nor anyone else is able to predict how long anyone has to live. With the rapid advances we are witnessing in more effective targeted therapies and better diagnostic tools, many once-deadly cancers are being converted to chronic illnesses, and the possibility of cure is on the horizon.  We have a responsibility to our patients, to be honest, but we also have a responsibility to never take away their hope.