Managing Cancer as a Chronic Condition

The past seven years have been eventful for Ellen Smith.

"I remarried. I've now traveled to England, Scotland, France and Italy," says the 66-year-old from Centennial, Colorado. "I love art and art history and so does my husband ... so that was a real treat to get to go and see the originals instead of just peeking at art books." Tracing some of her heritage to Scotland, she even managed to locate a castle built in the 1300s, once inhabited by her ancestors -- "with a family graveyard and everything." Also, during those past seven years: "Five new grandchildren have been born," Smith says.

She's done it all since 2008, when she was diagnosed with advanced-stage lung cancer, despite having never smoked. But she's not cancer-free. "April 6 ^th, I celebrated seven years living with cancer." Nor does she, or her oncologist, talk about her cancer as a terminal illness.

"With advanced-stage lung cancer, your chance of being alive one year after diagnosis is about 25 percent," says Dr. Ross Camidge, a lung cancer specialist who provides care for Smith at University of Colorado Hospital in Denver. Camidge has thrown any such attempt to determine a prognosis for Smith, who has undergone experimental therapies, out the window, however. "The great thing is, because she's surfing this wave of discovery, the rulebook hasn't been written," says Camidge, who is also an investigator and professor of medicine at the University of Colorado Cancer Center. Smith's care has included treatment with an initially experimental drug called crizotinib, made by Pfizer, which has since been approved by the U.S. Food and Drug Administration under the name XALKORI.

Camidge says that by determining the specific type of non-small-cell lung cancer Smith has -- which started in her left lung -- clinicians at UCH have been able to use more targeted therapies, like the drug. That's in addition to more traditional treatment, such as surgery to remove her left lung and chemo that she underwent at another local cancer center, where Smith says she was initially told she had six to nine months to live. "After that first year, they just came back to me and said, 'There's nothing else we can do for you,' which really was like a death sentence." She credits additional treatment options, including experimental therapy, at UCH with saving her life.

Camidge says that because medicine can now more precisely differentiate cancers and successfully target treatments to them, many patients like Smith are able to live longer with cancer. Though it varies by cancer type and individual circumstance, patients increasingly are able to live years following their diagnosis, and in some cases decades. Improved treatments have also generated discussion in clinical circles about the possibility of someday managing advanced-stage cancer like a chronic disease, such as one might diabetes.

"Between 'cured' and 'dying' there's this middle ground, which isn't just controlling cancer, it's really living with cancer ... thriving with cancer," Camidge says. "And Ellen's a great example."

Of course, the primary focus in treating cancer, experts note, remains the same. "The first thing is we try and distinguish between patients that have early-stage breast cancer versus those who have more advanced disease. Because certainly the goal in early-stage disease is always cure," says Dr. William J. Gradishar, a professor of breast oncology and a professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago. But for patients with more advanced breast cancer, he says the focus typically shifts away from curative therapy, toward controlling the disease -- prolonging life, reducing symptoms and adjusting therapies to reduce treatment side effects, or prescribing additional medications that address those side effects, like nausea.

While that's long been the standard of care, including in older patients and for those with slow-growing cancers who are more likely to die from causes unrelated to the cancer itself, treatment improvements mean some patients with advanced disease live longer with their cancer, says Gradishar, who also serves as chair of the Guidelines Panel for Breast Cancer for the National Comprehensive Cancer Network, an alliance of leading cancer centers. For example, "In hormone-sensitive breast cancer ... we can partner standard anti-hormonal therapy with new targeted therapies, and that's resulted in a significant prolongation of the time it takes for the disease to progress," he says. "So in many of these patients, again, it is very much like a chronic disease, where we watch patients carefully, but nothing is changing over longer and longer durations of time."

There are, however, still limits to the analogy and the reality of managing cancer for patients and doctors alike. Most notably: "[For] patients with advanced disease, we're not telling them that their lifespan will necessarily be normal," he says. In "advanced disease, we have a long way to [go before we can] say that it's the equivalent of treating long-term hypertension or long-term diabetes" -- which, in their own right, also have the potential to shorten one's life significantly if not well-controlled.

That means that with rare exception, such as those who have cancers that respond well to chemotherapy, including leukemia, lymphoma and testicular cancer, which can sometimes still be cured in advanced stages, Camidge says, most patients with advanced cancer are stuck with the disease. That still typically translates to a shorter life expectancy.

"There isn't one answer for everybody. There's no panacea for cancer," Camidge says. But he recommends that patients, at the very least, seek a second opinion about their cancer from an expert who specializes in their specific cancer type to ensure they're getting the most targeted therapy. That includes in instances where a cure isn't deemed possible, but controlling the cancer -- at least temporarily -- might be.

Gradishar also encourages patients to explore the possibility of enrolling in clinical trials. "Because only by investigating new things can we really turn this into a chronic disease," he says. However, with any treatment, experimental or approved, experts say it's important to first weigh all that's known about the potential benefits and harms, and to also discuss alternative options with your doctor, before making any decisions on care.

Additionally, should a shift toward managing cancer as a chronic condition ever become fully possible, Gradishar and Camidge say it would also require a mental shift for many patients, too. "While the C-word that people only ever want to hear next to cancer is 'cure,' the other C-word is 'control,'" Camidge says. Coming to terms with that idea, where a cure isn't possible but perhaps controlling cancer is, he adds, allows patients to get on with their lives.

For Smith, who has gotten used to changing treatments whenever her cancer spreads, that means looking forward to making more memories.

"I just realize how blessed I am, every day, just to be here," Smith says. "It sort of sounds like a cliché, but life really is better."

Michael Schroeder is a health editor at U.S. News. You can follow him on Twitter or email him at mschroeder@usnews.com.