We all feel disappointed, even uncomfortable, when therapy directed at the cancer process fails to change the course or the outcome of the disease in a patient of ours. That situation, often termed “therapeutic failure,” has, of course, many profound effects on the patient and family; but it also has an impact on ourselves as members of the medical team. Furthermore, it commonly affects our communication and our relationship with the patient and family. To use a current phrase, it often feels as if there is an “elephant in the room,”¹ a presence that drastically alters the manner in which we communicate and behave but which is rarely discussed openly or even acknowledged and, thus, may benefit from a fuller analysis.

I suggest that it is important for us to identify and acknowledge the effects of therapeutic failure on ourselves because, in that way, the impact will be ameliorated and we will find it easier to put more of our time and effort into supportive oncology, offering palliation and support for the patient and family. In this way, we are more likely to view supportive activities as successful in their own right and we are less likely to feel daunted, discouraged, or overwhelmed by the apparent failure of our therapy to change the course of the disease. In other words, the more we acknowledge the effects of therapeutic failure against the disease, the more easily we may direct our energies and efforts toward supporting the patient.

In this article, I shall briefly review some of the factors that may contribute to the effects of the unacknowledged “elephant” and I will discuss some of the ways in which those factors alter and intensify the emotional atmosphere. I shall then outline some potential approaches to reducing those effects on our practice.

Unanticipated Downsides of Success

Paradoxically, one of the most significant causes of disappointment in therapeutic failure is a factor that itself is rarely identified or discussed overtly: the effects of past successes. Several decades ago, early advances in chemotherapy produced dramatic and transformative effects on some cancers. Those effects have been rarely matched since then, but they greatly raised hopes and expectations. They set the bar high. In the 1960s and 1970s, the multiagent chemotherapy regimens for acute lymphoblastic leukemia of childhood and then MOPP (mechlorethamine [Mustargen], vincristine [Oncovin], procarbazine, prednisone) in Hodgkin lymphoma totally transformed the prognosis for those conditions. Despite some significant advances and great efforts since then, very few advances (with a few exceptions such as the platinum-containing combinations for the treatment of testicular cancers) have had such transformative effects, changing a condition from “almost always fatal” to “almost always cured.”