IM13.{6,14,16} | Cancer Treatment Decision Making — Summary & Reflection

KEY TAKEAWAYS

Curative intent: eliminates all cancer; accepts higher toxicity; feasible when disease is localised or highly chemosensitive; examples — radical surgery (R0 resection), radical chemoradiation (cervical cancer, head and neck), ABVD for Hodgkin lymphoma. Palliative intent: controls disease, maintains quality of life, prolongs life but does not cure; lower toxicity threshold; examples — palliative chemotherapy in metastatic CRC, palliative RT for bone or brain metastases, best supportive care.

Neoadjuvant therapy: given before definitive local treatment to downstage or treat micrometastatic disease (neoadjuvant chemoRT for rectal cancer). Adjuvant therapy: given after curative resection to reduce relapse risk.

Surgery: curative (R0 resection), debulking (ovarian cancer), palliative (decompression, stenting). Eligibility determined by stage, resectability, PS, organ function.

Radiation: fractionated to exploit 4Rs (Repair, Redistribution, Repopulation, Reoxygenation); radical RT (curative, organ-preserving), adjuvant RT (post-surgery), neoadjuvant RT (rectal cancer), palliative RT (8 Gy single fraction for bone pain).

Systemic therapy: cytotoxic (alkylating agents, antimetabolites, taxanes, anthracyclines); targeted (TKIs, monoclonal antibodies, PARP inhibitors); immunotherapy (checkpoint inhibitors: anti-PD-1/PD-L1, anti-CTLA-4); hormonal (tamoxifen/AIs for breast cancer; androgen deprivation for prostate cancer).

Patient-centred decisions: SDM integrates clinical evidence, patient values, and MDT recommendation. Financial toxicity, health literacy, and family-centred culture are specific barriers in India. PS 3–4 = cytotoxic chemotherapy typically causes harm; palliative care improves both quality of life and survival when integrated early.

REFLECT

Return to the two patients from the hook — both Stage III NSCLC, entirely different treatment plans. You have now learned the framework that explains that difference: PS, organ function, treatment intent, toxicity trade-offs, and patient preferences. Think about how you would conduct the first treatment discussion with each of these patients. Patient A: fit, curable-intent, high toxicity to be accepted — how do you explain the benefits and risks of concurrent chemoradiation honestly while maintaining hope? Patient B: limited by COPD and poor PS, palliative intent — how do you frame the goals of treatment without saying 'there is nothing we can do for you'? These are not abstract scenarios — they will be real conversations you will have within your first year of post-graduation. The language, the tone, and the structure of these conversations matter as much as the clinical decision itself.