The aggressive chemo fallacy

We are in a war, a war on cancer. We talk of battle and attack, magic bullets, proton beam rays, laser surgery and targeted drugs, doctors as combat commanders, patients as foot soldiers, the disease as the enemy, and defeating cancer in a titanic struggle against death.  Therefore, it may surprise you to know I am baffled and often take on a momentary blank stare when asked the common question, “Doc, is this aggressive chemotherapy?”

The paradox is that while we want to be fierce in our assault on malignancy, we do not rank chemotherapy by aggressiveness.  There is no one to 10 scale to rate chemo from gentle as a daisy to ferocious as tyrannosaurus rex.  Saying that a particular chemotherapy is more aggressive than another is like saying that oak is more aggressive than pine.  Oak is a hard wood, soft pine easier to work, but when you are building a house each has its place.  We do not say to the carpenter, “Whatever you do, use aggressive lumber.”  We choose chemo not by aggressiveness, but effectiveness.

I had a dental abscess not long ago and went to the dentist.  Before he drilled, he prescribed an antibiotic.  He picked the correct antibiotic for the particular infection.  The dentist did not order a more or less brutal antibacterial; he designed the specific therapy for my specific problem.

Confusion arises when patients ask, “is that chemo aggressive?”  The doctor has no adequate answer as there is no “how hard we hit it” scale.   Different chemotherapies have different side effects and are active in different combinations in different cancers in different patients. Therefore, it is likely the physician will not  clearly answer the question, adding to the patient’s turmoil.  I believe the aggressiveness question is really two issues hidden in one.

First patients must be reassured that the treatment is correct for that specific cancer and that the chosen treatment has the greatest probability of success.  He or she needs to know that the doctor is not compromising or leaving any therapeutic stone unturned.  The patient never wants to hear in the future; “Well, the chemotherapy did not work, so this time we will use a drug which is more likely to work.”  The patient wants to do everything to treat the cancer, demanding that the doctor be aggressive.

Second, it is a query about side effects.  There is confusion that the more side effects a chemotherapy agent produces the more likely it is too work.   The patient is saying, “Reassure me that this therapy does have side effects, because I know they are important.  I just want you to know I can take it. Doc, you can be the Mohammed Ali of oncology.  “Float like a butterfly – Sting like a bee.” Slug me hard and slug my cancer harder.  I want to live.”

However, this is like saying that the more pepper you put in the casserole, the more likely your guests are to enjoy it.   Too much pepper and the whole mess becomes intolerable; chemotherapy is the same.  Use the correct drug for the specific disease and give the correct amount; use too much and life becomes dominated by intolerable complications.

Cancer can often be treated without excessive side effects and side effects are not related to benefit. Targeted therapy for the specific disease given in a medically elegant manner can maximize healing while minimizing toxicity.  It is not necessary to turn each patient into a piece of dried bacon.  This is not to ignore the real toxicity of cancer therapy, which can at times be very hard on both mind and body, but to clarify that side effects are not part of the goal and choosing therapy is not a manner of how hard or how much but how correct.


  • Morris Burkett
    Very concise article. It makes sense. I was under the mistaken idea that the "rougher" the side effects the more effective the treatment. I should have suspected something when CHOP failed to produce better results that the fludara cocktail.
    • James Salwitz, MD
      Your CHOP (an intense chemo regimen for aggressive lymphomas) verses fludara (a simpler more focused regimen for low grade lymphomas and chronic leukemias) is the perfect example. Sometimes just changing from one to the other results in a significant change in anti-cancer effect which does not relate at all to the side effects of the therapy. jcs
  • Very interesting.!

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