Advanced cancer/ Stage 4: When Will I Die?

Advanced cancer/ Stage 4: When Will I Die?

Mr C, who is in his early 60s, was diagnosed with metastatic prostate cancer came with his two daughters for consultation. At the end of the consultation, one of the daughter accompanied her dad to go for venepuncture.

The other daughter stayed back and ask, “Doc, how long will my dad be able to live?”

At certain point of time, everyone, dies. I’m not trying to downplay dying.

It’s the inevitable end for all my advanced/ metastatic cancer patients. They knew about it.

Some will tell me that it’s a death sentence.

Some will tell me it’s their second chance to make amends or be closer to God.

When will I die? What do I tell them?

I told them, “I honestly do not know but not so quick”.

Unlike those who died suddenly from sudden cardiac arrest or fatal motor vehicle accident (there is no tomorrow for them), most of my patients will likely still be alive the next day, next week, next month or next few years, with appropriate treatments.

Multiple types of treatments, from palliative chemotherapy, biologic therapy, targeted therapy and now immunotherapy have allow many patients to live for years.

Besides, the emphasis on multidisciplinary discussions and use of multimodality treatments (surgery, intervention radiology, radiotherapy, etc.) help to improve survival even more.

Is Cure Still Possible in Stage 4 Cancers?

There is a subset of stage 4 cancer in which the volume of tumor spread is small and in limited number of lesions and sites (eg. spread to lung only or liver only).

These are termed oligometastasis.

Surgery has been shown to be able to cure a proportion of oligometastatic patients.

For patients who are reluctant to undergo surgery due technical reasons, co-morbidity or advanced age, local curative and ablative treatment with radiosurgery such as stereotactic body radiation therapy (SBRT) is a viable alternative.

SBRT has been shown to be safe and effective with local control rates exceeding 80% and similar to surgery also, is able to cure a proportion of oligometastatic patients.

Five year survival for different cancer sites (JNCI, 2017)

Improving Treatment and Longer Survival

The inevitable can be delayed as long as there are still treatments available and as long as patients agree for treatment.

  • Treatments for stage 4 lung cancer prolong survival more than 2-3 years now (M Reck 2016, Mok 2018)
  • Treatment for stage 4 colorectal cancer prolong survival more than 2 years (F Ciardiello, 2016)
  • More than 50% of advanced melanoma patients still alive after 2 years (J Schachter, 2017)
  • In advanced prostate cancer, 66% of patients are still alive at 3 years (Fizazi K, 2017)
  • Even for patients with advanced pancreatic cancer, which carry very poor prognosis, patients can now survive up to a year (Conroy T, 2011)

Other than having the best treatment for cancer, getting the fastest treatment is equally important.

Get on with your cancer treatment promptly.


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