What Oncologists Think About When Recommending a Cancer Treatment Plan

March 1, 2022
ASCO Staff

People with cancer, caregivers, and clinicians work together to choose the best treatment plan for the person’s specific cancer. There are many factors, both personal and medical, that go into evaluating treatment options. Some of these factors include the possible side effects of a specific treatment, the goals for the person’s treatment and recovery, and the person’s current health.

Oncologists are experts in evaluating the nature of cancer, how it’s treated, and the side effects of the treatments used. As treatments for cancer continue to improve, oncologists are constantly evaluating the best options for their patients.

You may wonder what tools oncologists use when they evaluate these different treatments, and how that impacts the choices you make for your care. Here, learn what oncologists consider when recommending a treatment plan for each patient.

What information does a doctor need to start recommending a treatment plan?

A doctor needs to know several things about your cancer to develop a treatment plan recommendation. Many of these details are collected when determining your cancer diagnosis. To make a cancer diagnosis, a person undergoes tests, such as a biopsy, blood tests, or imaging scans, to determine whether or not they have cancer. Sometimes, several different tests need to be done before a cancer diagnosis can be made. Often, these test results and descriptions are detailed in a document called a pathology report.

After diagnostic tests are completed, your doctor will review the results with you. If the diagnosis is cancer, these results also help the doctor describe the disease. This is called staging and grading (see below).

How does the type of cancer affect a suggested treatment plan?

The 4 most common types of cancer in the United States are breast cancer, lung cancer, prostate cancer, and colorectal cancer. But there are more than 100 other types of cancer. Cancers are often described by where they started in your body. For example, breast cancer starts in the breast, and it is called that even if it spreads to other parts of the body. 

Different types of cancer respond better to certain types of treatment, so the type of cancer is a key factor in choosing cancer treatments. For example, surgery may be one of the first treatment options for a person with early-stage breast cancer, along with other treatments. Meanwhile, surgery may not be recommended for people with certain types of lung cancer, where radiation therapy and chemotherapy may be better options.

A key discussion we have with a patient is that cancer is not one disease, and 2 cancers of the same type are not the same. Everyone’s cancer presents and behaves differently, everyone’s response and tolerance to therapy is different, and everyone has different expectations and goals of therapy. Decision-making with a patient needs to account for all these differences. Also, realize that the cancer continuum of care is a process. No 2 patients take the same path, and we have continued discussions with patients throughout that continuum.” – Jeffrey A. Meyerhardt, MD, MPH, FASCO, Douglas Gray Woodruff Chair in Colorectal Cancer Research, Clinical Director, and Senior Physician at the Gastrointestinal Cancer Center at the Dana-Farber Cancer Institute and the 2022 Cancer.Net Associate Editor for Gastrointestinal Cancers

How does the stage and grade of the cancer affect a suggested treatment plan?

The cancer's stage tells the doctor where a cancer is located and its size, if and how far it has grown into nearby tissues, and if it has spread to nearby lymph nodes or other parts of the body. Doctors describe the stage of most cancers on a scale of I to IV (1 to 4), but some types of cancer may include a stage 0 or use different terms. Meanwhile, the grade of the cancer describes how much cancer cells look like healthy cells when viewed under a microscope.

Cancer staging and grading helps doctors to design a treatment plan by:

  • Describing the aggressiveness of a cancer in terms of how quickly it can grow or spread

  • Understanding the risk of a cancer coming back or spreading after treatment

  • Estimating the chance of recovery or survival, called a prognosis

  • Comparing how treatments worked in other groups of people with a similar stage and type of cancer and other features

The stage and grade of cancer can help oncologists determine goals for treatments. Often, the goal of treatment is to cure the cancer. In other cases, the goal of treatment may be to slow cancer growth and improve someone’s quality of life.

What other information does the doctor collect from the tumor to develop a treatment plan?

For some cancers, including breast, lung, and colorectal cancers, doctors will test the tumor for other information beyond its size or spread, including any mutations, changes, or patterns in the tumor's DNA. This is called biomarker testing or tumor marker testing.

For example, some types of cancer are responsive to therapies that target hormones, called hormone therapy. When a cancer is responsive to treatment, it means that the treatment has slowed or stopped the growth of the cancer and, in some cases, has made it shrink. If a cancer becomes undetectable after treatment, it is called a complete response. So, for a person with breast cancer, the doctor might recommend an immunohistochemistry (IHC) test, which uses a sample of the tumor to determine whether the cancer is hormone receptor positive. When a tumor is hormone receptor positive, that means it expresses estrogen receptors (ER) and/or progesterone receptors (PR). Doctors will then use the results from these tests to help decide whether hormone therapy might be a treatment option for their patient.

Certain types of cancer have genetic markers that can make them more responsive to targeted therapies. For example, testing people with non-small cell lung cancer (NSCLC) for epidermal growth factor receptor (EGFR) and ALK mutations, which are changes in the genes, can help doctors decide whether to recommend specific targeted therapy drugs.

Ask your doctor whether they recommend biomarker testing for your cancer, and if so, how it could impact your treatment plan. Thanks to cancer research, new treatments in this area are being discovered regularly for more types of cancer.

“In addition to the above factors, biomarker testing is the most important component of treatment planning for a patient with a new diagnosis of metastatic lung cancer so that treatment can be individualized to each patient.” – Charu Aggarwal, MD, MPH, the Leslye Heisler Associate Professor of Medicine in the Hematology-Oncology Division at the University of Pennsylvania’s Perelman School of Medicine and the 2022 Cancer.Net Associate Editor for Lung Cancer

How are standard treatments decided upon? When will clinical trials be recommended?

“Standard of care” means the best treatments known. In the United States, the U.S. Food and Drug Administration (FDA) approves individual drugs and other treatments for specific uses after a long period of development, research using clinical trials, and regulatory review that shows the treatment is effective and safe. Your doctor knows which treatments have been approved to treat different diagnoses in their field of expertise.

In addition, several organizations, including the American Society of Clinical Oncology (ASCO), publish clinical practice guidelines that recommend to health care providers what they feel are the best treatments for a specific situation, such as treatments for a certain type of cancer at a certain stage. These guidelines help oncologists in their decision-making.

In addition to standard treatments, clinical trials are another option to consider during treatment planning, regardless of the stage or type of cancer. A clinical trial is a research study that tests a new approach to treatment, such as a new drug or a new type of surgery.

Sometimes, oncologists will talk with other oncologists for their advice on treatment, too, particularly if a treatment regimen is new or if it is part of a clinical trial. Advice from other experts about their experience treating other people with cancer can be invaluable. When a team of oncologists gather to discuss complicated cases and receive opinions from many specialists, it is called a tumor board.

When I’m making a treatment plan with a patient who has been diagnosed with breast cancer, I incorporate details about the cancer, such as the type and where it is located. Importantly, I also consider key information about the patient, including other medical issues that they have, as well as their wishes and preferences. Finally, I think about any clinical trials that they might be eligible for. It is only by taking into account both the cancer and the person that I can develop a truly personalized treatment plan for each patient.” – Norah Lynn Henry, MD, PhD, FASCO, Associate Professor in the University of Michigan's Division of Hematology/Oncology in the Department of Internal Medicine, Breast Oncology Disease Lead at the Rogel Cancer Center, and the 2022 Cancer.Net Associate Editor for Breast Cancer

What other health factors do oncologists consider when making treatment recommendations?

Certain medical conditions, like heart disease or diabetes, should be taken into account when planning cancer treatment and recovery. Because of this, your oncologist will review your full medical history before making any treatment recommendations. Learn more about what to know when cancer is not your only health concern.

An oncologist will also consider a person’s age when they recommend a treatment plan. Oncologists who treat people over age 65 are increasingly using geriatric assessments to decide which treatment options are best for their patients. Geriatric assessments identify problems that might not be captured during a traditional physical exam and are more common in this age range. It’s important to note that a patient’s age should be just one of many factors considered in making treatment recommendations.

Short-term and long-term side effects of treatment are also top of mind for oncologists when considering specific treatments. This includes talking with the patient about their goals for care and the physical, emotional, and social effects of cancer, as well as the financial impacts from treatment. Quality of life is an important consideration when making treatment recommendations, so the health care team will pay close attention to how treatments may impact someone’s overall comfort, well-being, and ability to partake in their usual tasks and the things they enjoy.

How important is patient-doctor communication during treatment decision-making?

The patient’s individual goals for treatment are critical to their doctor’s evaluation of the available treatment options. For example, your goal for treatment may be to slow the growth of the cancer, eliminate the cancer, or help you manage the symptoms and side effects from the cancer. Be honest about your goals for treatment with your oncologist so your treatment plan will include them. And, always ask questions about any part of your treatment planning that is unclear.

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