Tom Maguire always figured that, if he ever developed cancer, he would pursue the toughest treatment available. "You destroy yourself, and then you can come back," he said.
His view was tested earlier this year when he was diagnosed with bladder cancer that had invaded the muscle wall of the organ. The standard of care, he learned, usually involves removing the bladder. He would have the choice of permanently wearing a bag to collect his urine or having a difficult surgery to fashion a new bladder from his intestines. Both prospects filled the 63-year-old avid hiker and scuba diver with dread.
Then doctors at Philadelphia's Fox Chase Cancer Center told him about a new clinical trial designed to allow people with certain types of tumors to keep their bladders while being closely monitored.
Since getting into the trial a few months ago, "I have been walking on air," he said. "I guess you don't always have to take an all-in, nuclear approach."
For decades, "Big C" diagnoses sent patients and doctors scrambling for the most aggressive weapons to take into battle. The severity of the threat, as well as the limited knowledge of the disease and the pervasive use of military language to describe cancer, justified the blunt-force approach.
"Our focus historically on the 'war on cancer' implied that more is better and decimation is desired," said Justin Bekelman, a radiation oncologist at the University of Pennsylvania.
But today, the "fighting cancer patient" metaphor is falling out of favor, not only because it subtly blames patients who "lose the fight" but also because it doesn't capture a world of new biological insights, improved treatments and molecular tests that are transforming how cancer is treated.
At the root of the change is the recognition that not all cancers are the same: Some need to be bludgeoned, but others can be treated with more tailored therapies or simply watched. Equipped with new tools and evidence, oncologists are "deescalating" - cutting back on toxic and costly approaches likely to do more harm than good."Knowing when not to treat is great medicine," Bekelman said.
Yet for many patients, and even some doctors, doing less in the face of danger is emotionally and psychologically difficult. Reshma Jagsi, a radiation oncologist at the University of Michigan, said she sees women every day who look for the most aggressive treatment for breast cancer, even if it isn't needed. "They say, 'I need to be there for my kids, my students, my fill-in-the-blank,' " she said.
Increasingly, however, strong evidence for deescalation is spurring cultural and medical practice shifts. A landmark clinical trial published in June found that more than two-thirds of women with early stage breast cancer can safely avoid chemotherapy. Men with early stage, low-risk prostate cancer are rapidly embracing "active surveillance" over surgery - and avoiding possible complications such as incontinence and sexual dysfunction. And throat cancer caused by human papillomavirus, doctors now know, is different from other types of the disease, allowing a cutback in a brutal treatment regimen and reducing the risk of potentially devastating disfigurement.
In lung cancer, immunotherapy, which is usually less toxic than chemotherapy, has emerged as a first-line treatment for many patients. And people with advanced kidney cancer can skip surgery to have their kidneys removed and instead go right to drug treatment, a recent study showed.
The deescalation trend hasn't spread to all diagnoses. The most common form of thyroid cancer, which poses little risk, is often still treated with unnecessary surgery, experts say.
And some malignancies, such as pancreatic cancer, are so lethal that doctors are racing to find ways to ramp up treatment. A recent study found that certain patients who got a cocktail of four drugs lived longer than those on a single medication.