The journey of treating patients with advanced cancer, like metastatic gastric cancer, often brings clinicians face to face with difficult conversations surrounding prognosis, treatment goals, and emotional dissonance. As we make strides in cancer therapies, the complexity of managing patient expectations, cognitive awareness, and emotional resilience becomes more apparent, both for patients and clinicians.
A Personal Reflection on a Patient’s Journey
I recently treated a 50-year-old male patient who, despite having no significant prior health history, was diagnosed with metastatic gastric cancer with liver, peritoneal, and nodal metastases. We started him on a clinical trial of chemotherapy and immunotherapy. Fortunately, he experienced a durable response for nearly two years, an outcome far beyond the typical expectations for his condition. However, as with many patients facing advanced cancer, the disease progressed at the primary site, with symptomatic bleeding and peritoneal carcinomatosis.
The next phase of treatment required second-line therapy, where he experienced some benefit. Yet, the trajectory of his disease made it clear that responses would be less frequent and less durable, and the risk of treatment-related toxicities was increasing. The reality of progressive disease started to clash with his hope for a cure, as he requested a third-line therapy.
At this point, the balance between offering additional treatments and ensuring quality of life becomes delicate. As clinicians, we often experience cognitive and emotional dissonance when patients hold onto expectations of further treatment options or disease remission that may no longer be realistic. While I always hope for the best, preparing for the worst is a difficult yet necessary mindset in such cases.
The Importance of Early Prognostic Awareness
A recent article in The New England Journal of Medicine emphasizes the iterative process of improving prognostic awareness—an aspect I wish we had explored earlier in this patient’s care journey. According to the article, early referral to palliative care and timely discussions about the patient’s hopes, fears, and expectations can help patients better cope with their prognosis both cognitively and emotionally.
As I reflect on my patient’s experience, I realize how much we, as clinicians, also grapple with the hope that treatments like immunotherapy might provide a breakthrough. His two-year remission, well outside the expected survival curve, fed into our collective optimism. However, it’s crucial to recognize when that hope may conflict with the clinical reality and to guide patients through the process of adjusting their expectations.
Emotional and Cognitive Integration
One of the greatest challenges is managing the emotional oscillation patients experience—hopefulness for recovery on one hand, and the reality of disease progression on the other. This emotional dissonance is not only hard for patients but also taxing for clinicians. Over time, the patient may seek second opinions or more aggressive treatments, which in this case included a proposed harsh three-drug regimen by another physician.
In retrospect, I could have tempered my conversations about treatment efficacy more cautiously, gradually shifting from discussing active treatment to addressing the need for quality of life. The NEJM article highlights the role of palliative care in helping patients integrate their prognosis emotionally and cognitively, facilitating better coping strategies and improving their end-of-life experience and prognostic awareness.
Finding Common Ground
Ultimately, we moved toward a quality-of-life approach. Given his physical decline, weight loss, and increasing frailty, I suggested a short trial of Lonsurf, an oral therapy appropriate for his situation. Within six weeks, however, his condition worsened, and he passed away peacefully at home, surrounded by family.
Looking back, there are questions that remain—could I have initiated earlier conversations around prognostic awareness, or managed his expectations differently? The complexity of these discussions underscores the need for continuous engagement with the patient’s cognitive and emotional processing of their illness. It also highlights the importance of having these conversations over time, not just when treatment options start to narrow.
Lessons for Clinicians and Patients Alike
This experience serves as a reminder that improving prognostic awareness and integrating palliative care early can help both patients and clinicians navigate the emotional and cognitive challenges of advanced cancer. Conversations around hopes and expectations need to be ongoing, helping patients adjust to their evolving reality.
As clinicians, we must balance our own optimism with clear-eyed realism, guiding patients toward the best possible quality of life, even when the goal shifts from cure to comfort.
Disclaimer:
The clinical cases and stories shared on this blog are intended for educational and informational purposes only. All patient information has been de-identified in accordance with HIPAA regulations, and identifying details may have been modified, combined, or fictionalized to protect patient privacy. Any resemblance to actual persons, living or deceased, is purely coincidental. The views expressed are those of the author and do not represent the views of any employer, institution, or healthcare system.