Should Oncologists Use the Word?

It is the best possible news after an advanced melanoma diagnosis: A clean 10-year scan. This, in all likelihood, means the patient is cured and can leave the office free from their annual ‘scanxiety.’ 

But even in the best-case scenarios, oncologists may dodge the word cure, searching for others such as “remission,” “no evidence of disease,” and “most likely cured” to communicate the good news. Using these more open-ended terms can give patients reassurance without providing false hope that the cancer won’t ever return.

The “risk of future recurrence — even when very small — makes oncologists reluctant to use the word cure, fearing it will be interpreted as a promise, and particularly one that might be broken,” Belinda E Kiely, MD, and Martin R Stockler, MD, medical oncologists from The University of Sydney, Sydney, Australia, wrote in a recent editorial.

Is it ever safe for oncologists to use the word cure? Might doing so backfire? Or does a patient’s underlying fear of recurrence transcend the word?

A Word’s Heavy Impact

Part of clinicians’ hesitance to use the word cure may stem from a lack of accepted definition for the term in oncology.

For some experts, a cure means patients will have a normal life expectancy not affected by cancer. Being able to confidently tell a patient that “requires very long-term follow-up,” said James Larkin, PhD, a medical oncologist at The Royal Marsden Hospital, London, England.

The National Cancer Institute (NCI) has a similar definition: “Cure means that there are no traces of your cancer after treatment and the cancer will never come back,” the NCI website says.

The American Society of Clinical Oncology, however, defines cure much more narrowly, as “when a person’s cancer has not returned for at least 5 years after treatment.” 

Not having a standard definition of cure in oncology makes it even more challenging for an oncologist to know how to communicate that a cancer very likely won’t return, without overpromising.

Some of the hesitance in framing good news comes from nuances in prognoses that depend on the type and stage of cancer, explained Marleen Kok, MD, PhD, a breast cancer specialist from the Netherlands Cancer Institute in Amsterdam, the Netherlands.

Patients with localized early-stage breast cancer, for instance, have a 5-year survival rate of nearly 100%, and most live 2 decades or longer but, for some, the cancer will return.

“If you talk about early disease, indeed, we cure 80% of breast cancer patients,” Kok said last year, during a press conference at the annual 2024 European Society of Medical Oncology meeting. But sub-dividing breast cancer into tumor type adds complexity. “With triple negative breast cancer, if they relapse, they relapse during the first 2 or 3 years so, at 5 years, the majority are disease free,” Kok explained. “But that’s different for estrogen receptor positive breast cancer,” in which recurrences can come much later.

In advanced cancers, oncologists may, understandably, be more hesitant to use the word cure. However, ongoing progress in cancer treatments is making the prospect of a cure more likely for some patients.

Take recent findings in melanoma. The landmark CheckMate 067 study in advanced disease revealed that patients receiving the immunotherapy combination of nivolumab plus ipilimumab had a median melanoma-specific survival > 10 years and a median overall survival of about 6 years.

The findings from the trial suggest that “many patients may die from causes unrelated to melanoma — or, in essence, they are cured,” outside expert Elisa Funck-Brentano, MD, PhD, from Ambroise-Paré Hospital in Paris, France, explained to Medscape Medical News earlier this year.

With CheckMate 067, “what we’re talking about here is potential cure of metastatic solid tumors, which in general is something that’s new,” said senior author Larkin. In fact, late relapses after the 2-to-3-year mark in immunotherapy-treated melanoma are extremely rare, he said.

CheckMate 067 “really made people tempted to use the word cure, and I will say some people in our field do,” said Pauline Funchain, MD, a medical oncologist at Stanford Cancer Institute, and associate professor at Stanford University, Palo Alto, California. “The rest of us really, really want to, but are hesitant because of what we know about melanoma.”

Because the reality is late relapse is still possible.

The cancer can show up decades later and I think, as oncologists, that experience has sort of shaken us,” Funchain told MedscapeMedical News.

“Oncologists are scarred by those examples,” agreed Evan Hall, MD, a medical oncologist at Fred Hutch Cancer Center and assistant professor at the University of Washington School of Medicine, both in Seattle.

Clinical trials also don’t typically frame patient outcomes in terms of being cured. A recent analysis, which examined the use of “cure” and “hope” in 13,363 oncology articles published between 2000 and 2019 in JAMA Oncology and the Journal of Clinical Oncology, found that both words were used infrequently, especially in primary research articles, and their use decreased significantly over time, even as survival rates in oncology improved. The word cure, for instance, appeared in about 0.1% of sentences in primary research papers published in either journal, though the context of its use was not identified.

Outcomes in cancer clinical trials, which may assess hundreds even thousands of patients, are largely framed in terms of risks and rates of survival — 85% of patients who received treatment X are alive at 5 years or patients receiving treatment Y have a 20% risk for recurrence, for instance.

These risks and rates can’t tell an oncologist whether the patient sitting in front of them can close the cancer chapter of their lives for good.

“I just saw a patient the other day who was 30 years out from their melanoma diagnosis, and they had a recurrence,” Hall recalled. That’s why, “ultimately, it’s a hard thing to tell somebody they’re cured,” he said. “I personally don’t really like using that term.”

While the literature on using the word cure in oncology is limited, one older survey of oncology clinicians supports this view that many feel reluctant to use the term. Of 117 oncology clinicians who responded, 81% said they were “hesitant to tell a patient that they are cured,” and 63% said that they “would never tell a patient that they are cured,” while just 36% said they were comfortable saying the word, with most respondents waiting at least 6-10 years before doing so.

A more recent Italian survey, however, revealed a more favorable view of the word cure in oncology. The survey, which included 224 clinicians and 249 patients, reported that > 90% of cancer physicians, which included surgeons, radiotherapists, and medical oncologists, agreed that it’s possible for a patient to be cured, while about 84% of patients believed this. And > 80% of respondents said using the word cure would be “beneficial” to patients.

Still, even for those hearing the word cure and feeling comforted by an oncologist’s reassurance, it may only provide short-term relief. Fear that the cancer will come slinking, even roaring, back eventually may loom. And this lingering worry can haunt cancer survivors for years.

In a recent cross-sectional study of 229 adults who survived childhood cancer and had lived cancer-free for decades, researchers found that one third reported experiencing clinically significant elevated fear that their primary cancer would recur or a subsequent malignant neoplasm would develop. Similar anxiety has been documented in long-term survivors of adult-onset cancers.

To some degree, every survivor will experience fear and anxiety that their cancer will come back and, at a certain level, that is normal, the study’s senior author Nicole Alberts, PhD, a psychologist, associate professor, and Canada research chair in Behavioural Health Intervention at Concordia University, in Montréal, Quebec, Canada, told Medscape Medical News.

Although an oncologist’s words do matter and clinicians may wrestle with the right words for patients in the moment, it can take more than words to quell patients’ fear, she said.

“What we know about that kind of anxiety is that there’s this cycle where reassurance doesn’t really help in the long-term,” Alberts said. In other words, hearing the word cure from their oncologist initially makes people feel better, but the anxiety may eventually come back.

Alberts tries to help patients acknowledge and accept uncertainty while also calming residual or lingering anxiety about a cancer recurrence. Ultimately, Alberts’ goal is to help cancer survivors “find the sweet spot to live again.”

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for > 30 years about all areas of medicine.