“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”
― Sun Tzu, The Art of War
So a bit of brainstorming / mind dump ahead of a lecture on Saturday.
Oncology has come a long way in the last two decades. Some cancers, even when metastatic, have become chronic diseases. In particular this is the case for beast, colon and prostate cancer, and in some selected cases even lung cancer. This raises some important considerations about how oncologists approach the treatment of cancer.
In the past a die was cast and essentially the patient chose to take the poison (chemo) or not and if they took it and it worked then fantastic, and if not, well that’s the way it was meant to be.
Now, for many cancers, there are multiple lines of therapy. There are options for intermittent and maintenance treatment. And the paradigms are changing. In the past ‘systemic diseases’ were not treated with locoregional therapies but now it may be appropriate. We are moving to an era where the combination of targeted therapies and selective surgical cytoreduction, regardless of cancer type, becomes the norm rather than a situation where the rules are being broken.
So for the oncologist we must start thinking strategically about the goals of treatment.
If the aims change from achieving tumour response or prolonging life to cure (in the case of metastatic colorectal cancer) or achieving 5 year survivals in the metastatic setting then fundamentally different strategies are needed. Specific tactics we might pursue are maximal cytoreduction whether by chemical or surgical means, maintenance therapy, toxicity reducing therapy, planned treatment interruptions, immunotherapy and other maneuvers. Thinking not just what will be first-line therapy will be but looking ahead to the long-term strategy is required. Do you hold some treatments in reserve?
It is also important to think about chronicity and the effect it has on the whole person. I find my patients are stunned when I run out of conventional treatment options an yet they remain well, apart from the toxicities already inflicted. In this case there must be a lot of preparation for the eventual physical but not psychological surrender. It must be understood that many battles will be fought and won but the overall war could be lost but it doesn’t constitute giving up.
It must also be remembered that strategy is created in the midst of conditions of uncertainty. This can be communicated but only addressed by making life as normal as possible.
In addition to setting