Palliation in the era of so many treatment possibilities – how to know when to stop?
Dr Richard Lim Boon Leong, Hospital Selayang

The treatment of advanced lung cancer has been steadily advancing and over the past 2 decades, there have been a myriad of new treatment options as emerging targets for molecular targeted therapies continue to be studied. In patients with NSCLC, current management has evolved dramatically with the use of tyrosine kinase inhibitors towards targets such as EGFR, EML4-ALK, ROS1, NTRK genes. Immunotherapy with PD-1 and PD-L1 checkpoint inhibitor antibodies have also become major game changers in the battle against lung cancer. Despite all these advances, lung cancer remains as the major cause of cancer death worldwide and while these treatments may have some benefits to survival in some patients, these benefits are not sustainable. Hence the clinical decision to consider further lines of cancer therapy as the disease progresses requires the clinician to be very mindful about the goals of care for the individual patient. This should be done through a process of clear communication between the clinician and the patient along with significant other family members to ascertain at each point in the patient’s trajectory how the goals of care are weighed up. Comfort, survival and function are the 3 key factors to consider when deliberating on goals of care. This would require a good understanding of prognosis, benefits and harms of treatment as well as the possible outcomes. Ethical principles must also be considered with an understanding of medical futility being defined through shared decision making.