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Chasm of a Cure

Harpham, Wendy S. MD

doi: 10.1097/01.COT.0000350356.05477.b3
View from the Other Side of the Stethoscope

A newly diagnosed patient asks, “Doctor, can you cure me?” Elsewhere, a patient in remission asks, “So am I cured?” These patients are shocked and mystified if their oncologists hem and haw. “What's your problem?” they think. “It's not as if we're talking about sex.”

From profanity to prayer, few words mobilize the hearts and minds of patients like “cure.” But using this term in the context of survivorship makes me so uncomfortable I sometimes wish we'd ban it. Surely I can find a better solution.

Cure is a relative newcomer to the lexicon, making its entrance in the English language 700 years ago. Both the noun and verb are derivative of the Latin, cura—care.

Within decades, their meaning evolved from notions of care and caring to that of fix and fixing. Whether talking about medical illness or economic decline, a cure remedies the trouble. To be cured is to be free of the problem.

Before the 1950s, determining which cancer patients were fixed was as easy as 1-2-3: The relatively few patients who remained disease-free for five consecutive years could wear the “crown” of cure.

Then an explosion of innovations changed the face of medicine—from vaccines and antibiotics to heart surgery. In oncology, medical advances ushered millions of patients into long-term survivorship.

Ironically, as the public's hopes and expectations for a cancer cure soared, the five-year mark lost its luster. Why? Because survivors were living long enough for a notable number to develop late recurrences. Damn. They weren't cured, not in the rid-of-it-forever sense.

PCR studies and MRI scans revealed that remissions, like Baskin-Robbins ice cream, actually come in a variety of flavors. But the implications of designations such as “complete, undefined” and “molecular” remained unclear; for clinicians, the meaning of a cure became murky.

The uncertainty of remissions hit home when my post-treatment scans surprised everyone by continuing to improve for 11?2 years after I'd been declared in remission. Oops, those small lymph nodes attributed to scar must have been cancer.

Whenever I'm in treatment, newcomers to my history want to know, “Is it curable?” And when my cancer is in remission, they ask, “So are you cured?” These questions help explain why patients facing treatment decisions might underestimate the risks of aggressive treatments that offer hope of a cure, and why patients who choose not to go for the cure may feel defeated before they even begin.

Many patients describe a yearning to hear the three words they think will whisk “the other shoe” out of their lives: You are cured. Yet for those who hear those magical words, many still suffer from persistent anxiety and confusion: “Then why do I need a follow-up appointment? And why can't I give blood or check the donor box on my driver's license?”

To complicate matters, the intent-to-cure treatments responsible for the burgeoning population of long-term survivors predispose these patients to late effects, including second malignant neoplasms. Survivors are stupefied, “You're telling me I was cured of cancer, and now I have cancer?”

In contrast to the complexities of “a cure” in clinical situations, in the workaday world its meaning seems clearer than ever: a fix for cancer. On March 5th, President Obama “launched a new effort to find a cure for cancer in our time,” just as Nixon had declared a “war on cancer” in 1971.

Every which way you turn, people are asking for donations to foundations that promise to help fund or find a cure. “Scientists found a cure for polio; why not a cure for cancer?” they say.

I'm as guilty as the next, using the cachet of “a cure” to encourage donors to support Wendy's Eagles in the Dallas Lymphomathon. Guilty, because I'm knowingly taking advantage of a semantic twist: Vaccines cured the public health problem of polio by preventing the paralyzing illness; for unvaccinated patients infected and affected by the poliovirus, no cure for polio exists.

Along with millions of other activists, I quietly let donors believe their money will be funneled to help find a fix for patients suffering from this dreadful disease. I don't explain that much of the research will be aimed at preventing certain cancers and transforming other cancers from death sentences to chronic diseases, and thus curing the public health problem. I also neglect to mention that some of the money pays for education and supportive care services.

I've justified the deception by saying, “It helps raise awareness and loosen philanthropists' purse strings. Avoiding ‘a cure’ would only dash the hopes of patients and potential donors. And it would grant charlatans an unfair advantage in wooing vulnerable patients.”

People who mislead the public are often humanitarians just trying to help. But it's asking for trouble to encourage the public to expect the kind of cure that puts cancer in the same category as strep throat and appendicitis. Such expectations set the stage for distrust and disappointment, and discredit the remarkable advances that have been made.

Ah, the source of my discomfort about “a cure” is now clear: As a physician-survivor, I've been crisscrossing the chasm of “a cure,” unable to reconcile its meaning as a clinician with that as a patient.

The solution is not to ban the word, but to educate the public about cure's many meanings. In social and political contexts, we can help elevate the work of researchers and foundations by emphasizing the double entendre—a cure for the disease and a cure for the public health problem.

And when tending to patients, we can explain that being cured is no longer a simple dichotomy like being pregnant—you are or you aren't. Cure is a continuum. The ultimate goal is not always getting rid of the cancer forever, but healing the patient in front of us with expert and compassionate care.

Everyone benefits if we remember our roots and see “a cure” as part of our broader mission: “to care.”

© 2009 Lippincott Williams & Wilkins, Inc.
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