Author: Yusuke Sugama, MD, PhD

Medical Oncologist, Higashi Sapporo Hospital. ORCID iD: 0000-0003-2899-0512

The Blurring Lines of Treatment and Care

Have you ever prescribed a systemic therapy for an advanced cancer patient, fully aware that the biological benefit might be marginal, yet feeling it was somehow the “right” thing to do? When a patient says, “Continuing this treatment keeps me going,” we often find ourselves pausing. In those moments, I ask myself: am I still treating the tumour, or am I treating the patient’s need for hope and connection?

This everyday clinical dilemma points to a deeper issue in our current paradigm.

In advanced cancer, we have often treated without fully understanding what our treatments mean.

Pharmacological treatment in advanced, recurrent, and end-stage disease has long been part of routine clinical practice, yet it has rarely been defined as a distinct domain of care. 

Decisions about whether to initiate or continue treatment have often relied on individual clinical judgement—tacit knowledge, or even “art.” The purpose of such interventions has remained uncertain: to prolong survival, relieve symptoms, sustain hope, or respond to expectations within the clinical encounter.

Despite important attempts to conceptualise palliative chemotherapy, no unified framework has emerged. As a result, pharmacotherapy in advanced cancer remains an under-theorised area of practice.

A Changing Landscape

In recent years, however, the landscape has changed. Molecularly targeted therapies and immune checkpoint inhibitors have extended pharmacological intervention into stages of illness once considered beyond treatment.

Consider the following clinical realities:

• Clinical trials increasingly include patients with advanced disease.
• Systemic therapies are sometimes used even within hospice care settings. 

These developments represent more than therapeutic expansion. They reveal a shift in the meaning of treatment itself.

The distinction between “treatment” and “care” is becoming increasingly blurred. It is no longer clear where one ends and the other begins, nor what counts as benefit when tumour response is unlikely, survival gain is marginal, or treatment derives its significance primarily from the meanings patients and families attach to it.

The Limits of Existing Frameworks

This evolving reality exposes the limits of our existing frameworks. 

• Oncology: Traditionally oriented towards tumour control and survival, it offers limited guidance when biological benefit is uncertain, delayed, or modest. 
• Palliative care: Centred on symptom relief and quality of life, it does not fully capture the role that ongoing pharmacological treatment may play in shaping agency, hope, non-abandonment, and the lived experience of serious illness.

The result is a clinical space not adequately described by either field alone.

Integration essentially means delivering two distinct modes of care—tumour-directed and symptom-directed—in parallel. Yet, in current practice, the pharmacological intervention itself has become an existential act. We are not just adding palliative care alongside oncology; the very nature of what it means to ‘treat’ has transformed, demanding a new domain to evaluate it.

Three Dimensions of a New Domain

What is taking shape is not simply a better alignment of two existing disciplines, but the emergence of a recognisable domain of practice: advanced cancer pharmacotherapy. This domain is defined not only by the drugs it employs, but by the questions that govern their use. 

Three dimensions are central:

• Biological validity: the extent to which an intervention is supported by tumour biology and the likelihood of meaningful response.
• Clinical proportionality: the balance between possible benefit and burden, including toxicity, functional impact, and the demands treatment places on remaining life, especially when interventions may actively compromise quality of life near the end of life.
• Existential-relational meaning: the ways treatment intersects with patients’ values, relationships, sense of agency, and understanding of what matters in the time that remains.

Within such a framework, pharmacotherapy can no longer be judged by efficacy alone. It must also be understood as a practice situated within the broader human reality of advanced illness.

Deciding What Treatment Means

This reconceptualisation has important consequences. It challenges disease-centred models of indication and calls for context-sensitive decision making. It questions the dominance of endpoints such as survival alone, especially when patients consistently project expectations onto chemotherapy that diverge entirely from its biological reality. It invites the development of measures that better reflect meaning, experience, and proportionality.

It also suggests that clinicians must be trained not only to prescribe treatment, but to interpret what treatment signifies. This is not a future possibility. It is already part of everyday practice.

In advanced cancer, pharmacotherapy is no longer only a biological intervention. It is also a relational and existential act.

We are no longer deciding whether to treat. We are deciding what treatment means.

Take Home Messages

• Pharmacotherapy in advanced cancer is evolving beyond the traditional frameworks of both oncology and palliative care.
• A new clinical domain is emerging, requiring a balance of biological validity, clinical proportionality, and existential-relational meaning.
• Clinicians must shift their focus from merely deciding whether to treat, to interpreting what the treatment means to the patient’s lived experience.

Declaration of Interests:
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.