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Ronny Allan
An opinion post.
This subject comes up a lot in patient groups. The heterogeneity of Neuroendocrine Neoplasms (a term for both well differentiated NET and poorly differentiated NEC) tends to be forgotten as people start to make blanket statements as if it applies to every single NET patient. It becomes a rather circular discussion where certain readers might even be unnecessarily misled about their outcome casually suggested by someone who knows nothing about their diagnostic and treatment history.
Part of the problem is the official cancer terms built in the 1970s remain in use today, but they do not fit the vast changes that have occurred in cancer survival and treatment for incurable types. Consequently, specialists are generating new and informal terms, more individualised, when passing on updates to their patients. Some non-official or informal terms are just synonyms of published and universally accepted terms but are provided with more context to bring it up to date.
I wanted to cover the main terms below, where necessary bringing in commonly used synonyms which can mean more or less the same thing. I’m not suggesting the use of these synonyms are a bad thing because the official terms do need bringing into the 21st century.
Cure
I once wrote an article called “Neuroendocrine Cancer – can it be cured“. In that article, I covered the fact that most stage IV cancers (all cancers) are generally considered incurable, but I also added my own view of NETs being treatable in the same way a chronic disease would be. At the other end of the scale, I covered guidelines where doctors talk about removing tumours with “curative intent”, clearly in reference to small localized tumour scenarios. I’m pretty sure in my own mind that this does happen. As one example you only need to look at the epidemiology data on (say) small low-grade low-stage appendiceal and rectal NETs; to know that they rarely metastasise/recur, translated into guidelines as needing “no follow up” related to size and margin pathology score. However, in one sentence, “cure” generally means that there are no traces of your cancer after treatment and cancer will never come back. That’s a pretty big statement that seems impossible to predict in every single cancer patient. I guess doctors tread carefully before saying the word ‘cured‘. Epidemiology data plays a big part in decisions on how to guide doctors and manage patient expectations, i.e. based on the data collected over a period of years, doctors are able to assess the likelihood of a recurrence (as inferred above). For some doctors, I suspect they also base this on what they see in their own practices, at least in the larger hospitals seeing hundreds or thousands of patients over a period of time. When I read comments from members of my patient group, the lack of a standard is obvious. Words such as “stable“, “no evidence of disease” and “cancer free” are frequently used. Less quoted are terms such as “remission” or “cured“. I myself am “reassuringly stable” but with “evidence of disease“.
What does remission actually mean?
I looked at various sources and they all appear to say the same thing. Most sites you find will say something like this extract below, although I have added informed comments from one of my GoTo physician sources where there is always context rather than the bland statements from national cancer organisations:
Remission means that the signs and symptoms of your cancer are reduced. Remission can be partial or complete.
- Partial remission means the cancer is still there, but your tumour has gotten smaller, or you have less cancer throughout your body. Some doctors tell patients to think of their cancer as “chronic,” (author’s note: and this is relevant to locally advanced or metastatic Neuroendocrine Tumours (NETs). It’s something you may need to continue to check. If you’re in partial remission, it may mean you can take a break from treatment (where applicable) as long as the cancer doesn’t begin to grow again.
- Complete remission means that tests, physical exams, and scans show that all signs of your cancer are gone. Some doctors also refer to complete remission as “no evidence of disease (NED).” However, that doesn’t mean you are cured. Doctors can only make these statements based on their imaging (i.e. what can be seen by imaging) or suggested by other tests. But there is still a chance that cancer will come back later. For this reason, doctors cannot say for sure that you are cured. The most they can say is that there are no signs of cancer at this time (e.g. “No evidence of disease”).
If you remain in complete remission for 5 years* or more, some doctors may discharge you saying you are “cured” but I suspect they mean ‘unlikely to return’ as cancers that return, most do so within the first 5 years after treatment. In scenarios where there is a higher chance of recurrence, your doctor may monitor you for many years and do tests to look for signs of cancer’s return. Hopefully, in that time, they will also look for signs of late side effects from the cancer treatments you received (an area that perhaps needs more attention?). Another synonym is “cancer free” but that needs added context.
*Interest point. Some cancer types have smaller or larger remission checkpoints due to known behaviors. I have heard some NET specialists talking about 10 years and even beyond that with longer surveillance intervals in some cases (e.g. my CT scan has recently been extended from 6 months to 12 months due to ‘stable disease’ as one example, diagnosed Stage IV small intestine NET 2010 but with ‘evidence of remnant disease’).
Recurrence
Summary
For some in the Neuroendocrine patient community, this is both a controversial and emotional subject, understandably so. However, it is not helped by the ‘blanket statements’ continually made about all types of Neuroendocrine Cancer (Neoplasms) when they only really apply to a subset. Neuroendocrine Neoplasms are a heterogenous collection of cancers and this heterogeneity applies in various other ways, not just in the classification of the disease. Some group owners need to look at how they moderate these often-circular discussions. Some people introduce the subject of “micrometastases” which in some cases might be scary to some people causing totally unnecessary anxiety. Just because micrometastases can’t be seen, does not mean they are actually there. NET specialists should have a handle on which type of NET are more likely to recur than others although this is very individualised. The remission and stable definitions above apply regardless.
Other than the general cancer definitions I’ve quoted below, there is no real standard for what a doctor should say to a patient at relevant points in their surveillance in terms of the future, this really is not an exact science. I believe it has to be understood that this is really pretty much the way things are and thus why words need to be carefully thought through before being uttered.
But whatever is said to a patient, these words are really important, as is the context in which they are said. Consequently, it’s important to ask the oncologist or specialist specifically what they mean. Because one doctor may use any of them one way, and another doctor might use them in another context.
I personally think for those with more advanced Neuroendocrine Cancers (i.e. higher stages), as long as you continue to get surveillance, access to therapy (without insurance-based constraints where this is applicable), these terms then become less significant.
Thanks for listening.
Disclaimer
I am not a doctor or any form of medical professional, practitioner or counsellor. None of the information on my website, or linked to my website(s), or conveyed by me on any social media or presentation, should be interpreted as medical advice given or advised by me.
Neither should any post or comment made by a follower or member of my private group be assumed to be medical advice, even if that person is a healthcare professional.
Please also note that mention of a clinical service, trial/study or therapy does not constitute an endorsement of that service, trial/study or therapy by Ronny Allan, the information is provided for education and awareness purposes and/or related to Ronny Allan’s own patient experience. This element of the disclaimer includes any complementary medicine, non-prescription over the counter drugs and supplements such as vitamins and minerals.
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