Maurie Markman, MD
There are certain commonly used terms in the realm of oncology that may result in unintended consequences and should be considered carefully before being employed in conversation or in writing. When it comes to words clinicians use in talking with patients and their families, that list starts with the word “cure.” Of course, we know this word means the cancer is gone and will never return.
But when is it appropriate to declare that “the cancer is cured” for an individual? Surely, physicians today understand that the absence of evidence of disease at some arbitrarily defined point in time (eg, 5-year progression-free survival) does not equate with this hoped-for outcome, although it is certainly the case that the longer a patient goes without experiencing recurrence, the greater the probability that the end result will be a “cure.” In fact, cure can only be declared objectively in many advanced cancers after very extended periods of follow-up or when death occurs from a cause not related to cancer in the absence of signs of the malignancy.
Yet one of the most common questions that oncologists hear from patients must be, “Am I cured?” It is difficult to provide an objectively valid answer to this question, for as much as one may wish to definitively answer “yes,” the evidence in a given clinical setting may strongly suggest the danger associated with prematurely stating what that patient and family yearn to hear. As a result, great caution is advised when discussing the concept of a cure with a patient following a cancer diagnosis and in carefully distinguishing expressions such as “you are hopefully cured” or “you have a good chance of being cured” from the definitive “you are cured.”
Another term fraught with the potential for serious misinterpretation is the increasingly used expression “actionable” in reference to molecularly defined abnormalities within a patient’s cancer. It is common practice these days for commercial molecular laboratories to accompany their list of observed genomic findings with a statement that “action” is possible against 1 or more abnormalities. The problem is that the definition of “actionable” used by these entities is often substantially different from what might be considered reasonable by an objective external observer.
For example, does the existence of a small phase I trial with strict eligibility criteria for evaluating a novel antineoplastic agent in the molecular abnormality in question at a single academic institution more than 1000 miles from the patient’s home really make a genomic finding “actionable”? And if the patient is willing to undertake the journey, has insurance that will cover the costs of standard-ofcare charges, and meets all other eligibility criteria except for a prior history of a completely unrelated and inconsequential “benign tumor,” what can be said about the validity of the “actionable” claim?1 How can the abnormality be considered “actionable” if the patient realistically is unable or not permitted to act? The negative impact associated with the current usage of this terminology on the emotional and psychological well-being of such patients needs to be considered more carefully.1
Evaluating a “Conflict of Interest”
Next, we turn to the term “conflict of interest,” which is commonly used to describe a clinician or clinical investigator who has received financial payment from a commercial interest (eg, pharmaceutical, biotech, device company) for specific services such as advising on clinical trial design or serving as a member of a data safety and monitoring committee or a medical advisory committee. Although use of the expression without an additional modifier, such as “possible” or “potential,” may imply to some the existence of an actual conflict of interest, the mere listing of an individual’s name and the organizations providing payment is not problematic in most circumstances.