In this month's column I would like to respond to a question we received regarding choosing from a multitude of treatment options. The particular couple who contacts us (she has stage 1 breast cancer) was feeling virtually paralyzed by the variety of treatments that had been recommended in the literature they had read, and by advice from their various doctors.

Having to make difficult choices is an issue faced by almost everyone who has cancer. There are several reasons why this is the case. First, (unfortunately) modern medicine is not perfect and, in most cases, there is no definitive "gold standard" of care for a particular type or stage of cancer. As well, the relatively recent movement toward cooperation and participation in medical decision-making has drawn the patient and their family members into this difficult process. Certainly participation and teamwork have advantages, but there also clearly are drawbacks and difficulties in this approach.

Modern cancer treatment is an exciting, progressing, and vastly expanding field. We have all read about new theories and treatment possibilities, some (prematurely it seems) expressing the promise of a cure to all cancers). Unfortunately we are not there yet. What we are left with is a variety of approaches, including surgery, chemotherapy, radiation therapy, and immunotherapy. Not all physicians will agree on one approach to treatment of a particular cancer. Understandably, a specialist in any of the treatment areas may tend to recommend their particular approach first and foremost.

Some words of advice:

1. Talk to several different physicians.
   Since this can be time consuming, emotionally draining (and potentially expensive), use your own intuition and judgement or borrow from trusted friends and family members as to when you have gotten enough opinions.

2. Examine the doctors' openness to other approaches.
   Also determine your doctor's interest and availability in cooperating with other specialists. Your doctor may have access to regular team pre-treatment conferences or Tumor Boards where your case can be discussed by a number of specialists and a consensus approach recommended. Ask about these! Also, your primary care physician may be a useful guide and sounding board. He or she may be able to be an objective third party in helping you to sort out conflicting points of view.

3. Address quality of life issues.
   Quality of life issues can be very important and may or may not be addressed by various specialists. You are the person best able to judge your own fears and tolerance levels of the various side-effects or nature of different treatments. For example, a busy working mother may choose to have more frequent/more intensive chemotherapy that lasts a shorter duration, so she can return as quickly as possible to her responsibilities. The potential for more severe side effects may be outweighed in her life by the necessity of "getting it over with". On the other hand, someone with less life pressures might opt for a longer, gentler course of chemotherapy. These examples are obviously oversimplified (the mother might also have equally good reasons for choosing the slow approach) but the point is that these issues need to be factored into the decision-making process.

4. Determine your level of involvement.
   It can be difficult deciding how involved to be in treatment decisions. Some people are sure they want to jump into the fray and feel reassured by doing research, searching the Internet, and talking with experts. Others are much more comfortable with "old-style medicine", sitting back and letting a trusted expert make the decisions. For most of us, however, it is more complicated. One may want to participate, but at the same time feel exhausted, overwhelmed, and confused. This is where I plug some sort of arena for addressing the feelings themselves, be it individual counseling, a support group, or a trusted medical professional, clergy member, or family member/friend. Working through these feelings can often help clarify the complex issues involved, and even if not providing a specific answer, point toward the most comfortable approach or compromise in finding a direction.

5. Accept you are doing the best you can.
   Eventually, acceptance that you have done the best you can is important. There are no guarantees; accepting the unknown is one of the difficult tasks of living one's life - during and after cancer treatment. Don't drive yourself nuts over-analyzing and second-guessing. Living with cancer and after cancer benefits from a "one day at a time" approach. Learning to lower stress, relax, and forgive are helpful (though certainly difficult) strategies for facing the challenges ahead. Remember: overall healing can take place in many ways.

Be well.