Cancer treatment planning: personalised to the whole you

Once a Cancer diagnosis is confirmed and we understand its type, stage and biological characteristics, the next question is one of the most important: what is the right treatment approach for you? As a Medical Oncologist, this is where much of my role begins. The biology of the disease, the available scientific evidence, the expected benefit from treatment, your general health, other medical conditions, potential side effects, lifestyle, responsibilities and what matters to you all influence the final decision.

A multidisciplinary approach to Cancer care

Cancer treatment often involves more than one specialist. Depending on the Cancer and the clinical situation, treatment decisions may need input from medical oncologists, surgical oncologists, radiation oncologists, radiologists, pathologists and other specialists relevant to that particular Cancer. When multidisciplinary discussion is important, I work with the appropriate specialists to consider not only which treatments are needed, but also their sequence and timing.

Questions we ask together often include:

• Should treatment begin with surgery, or would treatment before surgery improve the outcome?
• Is radiation required?
• Should systemic treatment be given before or after surgery?
• Is there a biomarker or molecular alteration that changes the treatment choice?
• Is every component of treatment necessary for this individual?

Sometimes, choosing the correct sequence of treatment is as important as choosing the treatment itself.

First, we define the goal of treatment

Before starting treatment, I believe patients and families should understand what we are trying to achieve. For some Cancers, particularly when diagnosed at an early or locally advanced but potentially curable stage, treatment may be given with the aim of cure and reducing the risk of the Cancer returning. For advanced Cancers, treatment may aim to control the disease for as long as possible, prolong survival, relieve symptoms and maintain quality of life.

Understanding the goal helps us discuss the expected benefit realistically, and decide whether the potential side effects, inconvenience and impact on everyday life are justified by that benefit.

Choosing the right Cancer treatment

Modern Cancer care includes several different forms of treatment, often used together or in sequence.

Chemotherapy

Chemotherapy remains an important and highly effective treatment for many Cancers: to cure Cancer, reduce the risk of recurrence, shrink a tumour before surgery, control advanced disease, or relieve symptoms. The important question is not simply whether chemotherapy can be given, but how much benefit it is expected to provide in this particular situation. When I recommend chemotherapy, I discuss why it is being used, the expected benefit, possible side effects, how we can prevent or manage those effects and whether the dose or treatment intensity needs to be adapted to the individual. See Chemotherapy for how different regimens and their side effects differ.

Targeted therapy

Some Cancers have specific proteins, molecular alterations or biological pathways important for their growth. When a clinically relevant target is identified, targeted therapy may allow us to interfere with that pathway directly. Targeted therapy is not automatically better or easier than chemotherapy — it has its own benefits, limitations and potential toxicities. Examples include HER2-directed treatments in appropriate breast and other Cancers, and therapies directed against EGFR and other actionable driver alterations in selected lung Cancers. This is why biomarker and molecular testing can be valuable when the result has the potential to change treatment. The purpose of precision oncology is not to perform every available molecular test. It is to identify the right test, at the right time, when the result can meaningfully influence a treatment decision. See Targeted Therapy & Molecular Testing.

Immunotherapy

Immunotherapy has transformed treatment for several Cancers by helping the immune system recognise and attack Cancer more effectively, but it is not appropriate for every Cancer or every patient. Its usefulness depends on the Cancer type, stage and extent of disease, previous treatments, and relevant biomarkers such as PD-L1 expression, mismatch repair deficiency or microsatellite instability, and other tumour-specific characteristics may help guide the decision. The important question is not simply whether immunotherapy can be given, but whether there is good evidence that it is likely to benefit this particular patient at this point in their treatment. See Immunotherapy.

Hormonal or endocrine therapy

Hormone-sensitive Cancers, particularly many breast and prostate Cancers, may respond very well to treatments that interfere with hormonal signalling. For appropriately selected patients, endocrine therapy can provide prolonged disease control and may sometimes be combined with targeted therapies to improve outcomes.

Surgery and radiation therapy

Surgery and radiation therapy remain fundamental components of Cancer treatment. Their role depends on the Cancer type, location, extent of disease and overall treatment goal. Treatment planning considers the entire journey, rather than treating surgery, radiation and systemic treatment as separate decisions.

Treatment before and after surgery

Neoadjuvant treatment

Treatment given before surgery is called neoadjuvant treatment. Depending on the Cancer, this may involve chemotherapy, immunotherapy, targeted therapy, hormonal therapy, radiation or a combination. The aim may be to shrink the tumour, improve the possibility of complete surgery, allow a less extensive operation, treat microscopic disease early, or assess how the Cancer responds to treatment.

Adjuvant treatment

Treatment given after definitive surgery is called adjuvant treatment. Its purpose is to reduce the risk that microscopic Cancer cells remaining elsewhere in the body could eventually cause the Cancer to return. Whether additional treatment is worthwhile depends on factors such as pathological stage, lymph-node involvement, tumour biology, grade, relevant biomarkers, the expected risk of recurrence, and the expected magnitude of benefit against the patient’s health and preferences. The important question is not simply whether another treatment is available. It is whether the expected reduction in recurrence risk is meaningful enough to justify that treatment for the individual patient.

When Cancer cannot be cured

An advanced Cancer diagnosis does not mean there is nothing meaningful to do. Many advanced Cancers can now be controlled for prolonged periods using sequential treatments. In this setting, treatment decisions require a careful balance between controlling the Cancer, prolonging survival, managing symptoms, minimising unnecessary toxicity, and preserving independence and quality of life.

Supportive and palliative care can also be integrated alongside active Cancer treatment whenever needed. Palliative care does not mean stopping Cancer treatment or giving up — its purpose is to improve quality of life by addressing symptoms and concerns such as pain, nausea, fatigue, nutrition and psychological distress. Cancer control and quality of life should not be viewed as opposing goals. See Beyond Cancer Treatment.

Personalised Cancer treatment means more than a molecular test

Precision oncology is often associated with genomic and molecular testing, and these tools can be extremely valuable when they answer a specific clinical question. But personalised Cancer care goes further than the tumour’s molecular profile. When I formulate a treatment plan, I look at two equally important dimensions.

Two people with apparently similar Cancers may therefore appropriately receive different treatment plans. That is not a departure from evidence-based medicine — it is evidence-based medicine applied to the individual.

Shared decision-making

I do not believe treatment planning should simply be a doctor telling a patient what to do. My responsibility is to explain what we know about the Cancer, what treatment options are available, what the scientific evidence tells us, the expected benefit of each option, possible side effects, areas of uncertainty, and my medical recommendation.

Your role in that decision is equally important. You bring your priorities, concerns, responsibilities and understanding of what matters in your life. Together, these perspectives allow us to arrive at a treatment plan that is both scientifically sound and personally appropriate.

Treatment planning is an ongoing process

A Cancer treatment plan is not fixed forever. Throughout treatment, we continue to reassess: is the Cancer responding, are the side effects manageable, has new information become available, has the balance between benefit and toxicity changed? If treatment is working, we continue it appropriately. If it is not achieving its purpose, we reconsider the strategy, and if toxicity becomes significant, doses, schedules or treatments may need to be modified. And as new information about the Cancer emerges, the plan may evolve. Good oncology care requires both a clear plan at the beginning and the willingness to adapt that plan when the evidence in front of us changes.

Scientific evidence tells us what treatments can work. Understanding the biology of the Cancer helps us identify which treatments are most relevant. And understanding the person in front of me helps determine how that evidence should be applied. Every treatment decision deserves a reason: a reason grounded in science, appropriate to the Cancer and aligned with the whole you.

For me, personalised Cancer care means seeing both the Cancer and the person living with it. Treatment should be personalised not only to the Cancer’s molecular profile, but also to the person’s health, priorities, responsibilities and goals. If you have recently been diagnosed with Cancer or are considering treatment options, I am happy to talk you through a detailed, personalised treatment plan.

This page is general information and not medical advice for your situation. Treatment planning depends on a full clinical assessment. Medically reviewed by Dr Sneha Kommineni.