Were You Just Diagnosed with Cancer? Here are 5 Important Things You Need to Ask Your Oncologist:
Hearing the “C-word” is a life-changing moment. It is something you never expected to hear. You feel wholly unprepared to navigate the challenges ahead.
In that initial moment, you have a million thoughts enter your mind: You wonder if this was preventable— perhaps if you had healthier habits in your adolescent years. You realize you want to spend more time with your loved ones. You want to accomplish everything on your bucket list. You start to call your attorney to draw up your will. You wonder how you can accomplish your goals if you only have months, or maybe just weeks, to live?
It is important to take a step back and realize one key fact— not all “cancers” are the same.
To put it in simplest terms, cancer is a disease defined by unregulated growth of abnormal cells in your body. Cancer can originate from just about anywhere, and each tissue (or “site of origin”) can give rise to different types and subtypes of cancer. It is important to know the type/subtype of cancer, as the behavior, prognosis, and treatment of each cancer varies considerably. To complicate matters even further, two patients with the same subtype of cancer may have dramatically different treatment options and prognoses due to differences that exist at a cellular and molecular level.
Navigating these details while dealing with your emotions is challenging. As a cancer doctor, I’ve come to recognize that most patients don’t know where to start or what to ask. Here are the 5 most important questions that you should ask your oncologist about your cancer diagnosis:
1. What is the exact diagnosis?
This may seem obvious, but it is the most important question. Not all cancers are created equal. For instance, prostate cancer tends to be slower growing than lung cancer, and in many cases, it does not require any treatment other than watchful waiting. It is also important to know the subtype of cancer. Small cell lung cancer is a very aggressive type of lung cancer compared to non-small cell lung cancer, and it tends to have a more unfavorable prognosis. Acute leukemia behaves very differently from chronic leukemia, and they are treated very differently.
This is why your oncologist will make every effort to identify the exact diagnosis, as the treatment and prognosis will be determined by the type/subtype of cancer you have. Most of the time, you will need a biopsy (a tissue sample), and your oncologist can help determine the safest and least invasive site to sample. After your biopsy, it can take a few days to a couple weeks of testing to determine the exact diagnosis.
2. Can you explain the stage and what it means?
In most solid-organ cancers (i.e., lung, breast, colon, prostate), knowing the stage of the cancer is important for two reasons: oncologists use the stage to determine whether cancer is curable, and to determine the best approach to treatment. Staging is typically designated from I to IV, in which stage IV typically implies that the cancer has metastasized (spread) to distant organs. In order to determine staging, you will have to have imaging tests such as CT, MRI, or PET scans to evaluate if the cancer has spread from its site of origin. You may need to undergo another biopsy to confirm spread to a distant site.
The non-solid organ cancers (i.e., leukemia, lymphoma, multiple myeloma) do not follow the same staging system, but often have other staging methods that the oncologist will utilize to determine a risk-based treatment approach.
3. Is it curable? If not, is it treatable?
Early-stage cancers are treated with the goal to cure, often with combination modalities such as surgery, radiation, and chemotherapy. This often involves the care of multiple different specialists including a cancer surgeon, a radiation oncologist, and a medical oncologist. Treatment regimens tend to be more aggressive (meaning treatments are more likely to cause side effects in the short run) in order to maximally treat the cancer in the hopes of achieving cure.
Late-stage cancers are usually incurable, and the overarching goal of treatment is to limit the cancer’s effects on the patient’s quality of life for as long as possible. The word “incurable” should not be confused with untreatable. Many of the typical chronic medical conditions such as hypertension and type 2 diabetes are incurable, but they can be successfully treated for years. The same can hold true for advanced-stage cancers. The goal of treating late-stage cancer is to use medical therapies to control cancer growth and limit symptoms caused by the cancer, without causing excessive side effects from the treatment itself. Your oncologist can prescribe medical therapies to control the cancer as best as possible while minimizing the side effects of such therapies.
In select older and frail patients, cancer may be untreatable. What does untreatable mean? It means the available therapies are more likely to cause harm and are unlikely to meaningfully improve the patient’s survival. In these cases, the oncologist will recommend supportive treatments to help alleviate cancer symptoms, and referral to hospice care to focus on comfort measures at the end-of-life.
4. What is the frontline treatment approach? Are there any clinical trials I should consider?
Once the exact type and stage of cancer is determined, your oncologist will discuss with you the frontline treatment plan. For early-stage cancers, this will require referral to a surgical specialist who will determine if you are a candidate for surgery. You may have additional tests in order to determine if you can safely undergo surgery. After surgery, you may need radiation or chemotherapy (called adjuvant therapy) in order to treat any residual cancer.
If the surgeon feels that the tumor is inoperable, he may recommend medical treatment to “shrink” the tumor so that it becomes operable (called neoadjuvant therapy). Neoadjuvant therapy involves initial treatment with chemotherapy and/or radiation followed by surgery to remove the tumor. In other cases, he may recommend an entirely non-surgical approach where the tumor is treated intensively with radiation, chemotherapy, or a combination of the two (called definitive chemoradiotherapy)
If the cancer is incurable, the approach to treatment is usually medical therapies (called palliative chemotherapy). The frontline therapies differ on the type/subtype of cancer and can even vary among patients with the same type of cancer (see next point). You should talk with your oncologist about all available treatment options and have a detailed discussion about the risk and benefits of each option. It is also important to inquire about any clinical trials for which you may be a candidate. Clinical trials are studies looking at experimental therapies for your type of cancer, and it would be worthwhile to consider a clinical trial if you do not have a lot of treatment options available in the frontline.
5. What genetic and molecular tests do I need?
Once you know your diagnosis, ask your oncologist if there are any molecular and genetic testing that are necessary. These are tests that can be run on your biopsy specimen or on a sample of your blood. They can provide valuable information in 3 ways.
First, these tests may give information about the behavior of your cancer and may help the oncologist provide you a more accurate picture of your prognosis. For instance, in many acute leukemias, certain genetic mutations suggest a higher risk of resistance to chemotherapy, and a higher chance of relapse after initial treatment. These patients may benefit from advance therapies such as stem cell transplantation in order to decrease their risk of relapse.
Second, these tests may reveal an aberration in the cancer cells that can be treated with non-chemotherapeutic drugs. For example, cancer cells overexpressing a marker called PD-1 may allow them escape regulation by the immune system. By using a PD-1 inhibitor drug such as Pembrolizumab (a type of immunotherapy), you can take the “brakes” off the immune system to target and kill cancer cells.
Third, genetic testing may also provide valuable information in preventing additional cancers in you and your family members. Women who carry the BRCA1 or BRCA2 gene mutations are greatly increased risk of developing breast and ovarian cancer, and benefit from prophylactic mastectomy and oopherectomy. BRCA mutations are hereditary, meaning they can be passed on to the patient’s children, and thus testing for these mutations can help with primary cancer prevention in the next generation.
All information presented here is provided in good faith. The medical/health information provided in this article is for general informational and educational purposes only and is not a substitute for professional advice. The use or reliance of any information contained on the site is solely at your own risk.