REVIEW

CURRENT
OPINION ‘Curative’ treatments and palliative care: the lack
of consensus
Jan Gaertner a,b,c, A. Knies d, F. Nauck e, R. Voltz d, G. Becker a,b,c, and
B. Alt-Epping e

Purpose of review
A survey was performed to assess whether authors who report about palliative treatments or palliative care
share a common understanding of ‘curative’ treatments.
Recent findings
Of 107 authors from publications about cancer who used both ‘palliative’ and ‘curative’ in the same
abstract, 42 (39%) responded. The majority (n ¼ 24; 57%) understood ‘curative’ treatments as ‘aimed at
complete absence of disease for the rest of life’, but 43% (n ¼ 18) did not share this view. For example,
19% (n ¼ 7) stated that the term describes cancer-directed therapy for prolongation of life or even
regardless of the aspired goal.
Summary
In the care for cancer patients, unambiguous terminology is essential for the participatory and
interdisciplinary decision-making process. Clinicians, researchers and policy makers should be aware of
the difference between curative and disease-modifying therapies. Otherwise, this may be a major source of
misunderstandings as disease-modifying therapy may be indicated in the incurable stages of the disease as
well. In these palliative situations, it is essential to identify the realistic aim(s) of the therapy: prolongation of
life, alleviation of suffering or both.
Keywords
advanced cancer, curative treatment, decision making, early palliative care, quality of life

INTRODUCTION Such a diverging understanding of central

Palliative care is an integral part of the care for
patients with life-threatening diseases [1]. The
importance of this issue has become increasingly
recognized, and current recommendations advocate
the integration of palliative care early in the disease
&&
[2 ]. This necessitates close interdisciplinary com-
munication and unambiguous terminology concern-
ing the illness trajectory and available treatment
&
options [3,4 ]. Yet, a close look at the use of the term
‘curative’ in palliative care literature reveals incon-
sistencies: ‘palliative’ and ‘curative’ are used dichot-
omously in some publications and definitions [5–7],
whereas other documents state that ‘curative’ and
‘palliative’ interventions may be applicable at the
same time [e.g. Center to Advance Palliative Care
(CAPC); Fig. 1]. Other guidelines (American Thoracic
Society 2008 [8]) explicitly use ‘curative’ synony-
mously with ‘restorative’. This may not only be
caused by a diverging understanding of palliative
care, but also because of an ambiguous or even con-
flictive understanding of the term ‘curative’.
terms poses the risk of severe misunderstandings in
interdisciplinary communication. These would be
particularly relevant for the clinical setting such as
in case conferences (e.g. tumor boards). Moreover,
such terminological confusion could render a com-
mon understanding of documents such as palliative
(cancer) care guidelines impossible. Consequently,
this issue is of high relevance for palliative care policy
development and clinical practice.
a
Department of Palliative Care, University Hospital Freiburg,
b
Comprehensive Cancer Center Ludwig-Heilmeyer, Freiburg,
c
Competence Center Palliative Care (KOMPACT), Baden-Württemberg,
d
Department of Palliative Care, University Hospital Cologne, Cologne
and eDepartment of Palliative Medicine, University Medical Center,
Göttingen, Germany
Correspondence to Dr Jan Gaertner, Department of Palliative Care,
University Hospital Freiburg, 79106 Freiburg, Germany. Tel: +49 761
27095412; fax: +49 761 27095414; e-mail: jan.gaertner@uniklinik-
freiburg.de
Curr Opin Oncol 2014, 26:380–384
DOI:10.1097/CCO.0000000000000099

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 ‘Curative’ treatments and palliative care Gaertner et al.

Two independent researchers assessed the

KEY POINTS

The term ‘curative’ is often used even in the context of
incurable and life-limiting (palliative) diseases.

In such palliative situations, the lack of a common
understanding of the term ‘curative’ may be a
substantial source of misunderstandings when talking
about the realistic benefit patients might expect from
the available treatment options.

From the view of most authors, curative treatments aim
at the eradication of the disease and must not be
confused with disease-modifying therapy.

Disease-modifying therapy might be applicable in the
treatment of both curable and incurable, life-limiting
(palliative) diseases.

In a palliative situation, disease-modifying therapy (e.g.
chemotherapy) can aim at prolongation of life, the
alleviation of suffering (e.g. symptom control) or both.
The aim of this study was to assess whether
authors who report about palliative treatments or
palliative care share a common understanding of
the ‘curative’ treatments.
MATERIALS AND METHODS
A survey was performed among authors who used
both ‘palliative’ and ‘curative’ in the same abstract
or title of their publication, related to cancer
patients. Publications were identified by a system-
atic Medline search via PubMed. As this study aimed
to assess a realistic sample of the relevant literature
rather than performing a highly sensitive search, we
decided not to conduct an additional Embase
search. The main inclusion criteria for this literature
research were (Table 1)
screened titles and abstracts. From the studies that
met the inclusion criteria, the mail addresses of the
corresponding authors were obtained. Additionally,
we included all 29 authors of the last years’ National
Comprehensive Cancer Network (NCCN) guidelines
for palliative care, because this is a central document
and treatment guideline. The NCCN guideline also
uses the term ‘palliative’ and ‘curative’ in a single
sentence (though from the context a rather dichot-
omous understanding of the two terms could be
assumed). From January to April 2013, the authors
were contacted by e-mail.
This e-mail contained the following question:
‘Which of the following seven definitions of
‘curative treatment’ did you take as a basis for your
publication in the context of cancer care?’
(1) cancer-directed (disease-modifying) interven-
tions aimed at complete absence of disease for
the rest of life;
(2) cancer-directed (disease-modifying) interven-
tions aimed at complete, durable remission last-
ing at least 5 (–10) years;
(3) cancer-directed (disease-modifying) interven-
tions aimed at prolonging life;
(4) cancer-directed (disease-modifying) interven-
tions with rehabilitative and restorative aims;
(5) cancer-directed (disease-modifying) interven-
tions regardless of the aspired therapeutic goal;
(6) any interventions (not necessarily cancer
directed) aimed at prolonging life;
(7) other (please explain): (free text).
If necessary, the authors were reminded via
e-mail 2 weeks after the initial contact.
All responses by 15 May 2013 were included in
the analysis.

(1) title, abstract or MeSH term included both

‘palliati’ and ‘curati’; RESULTS
(2) years of publication (2002–2012); Our literature research yielded 107 hits. Two authors
(3) language of publication (English or German); appeared twice, another one was one of the authors
(4) covering palliative care for cancer patients. of this publication (J.G.) and for one publication

Palliative care is specialized medical care for people with serious illnesses. It is
focused on providing patients with relief from the symptoms, pain, and stress of a
serious illness—whatever the diagnosis. The goal is to improve quality of life for both
the patient and the family. Palliative care is provided by a team of doctors, nurses, and
other specialists who work together with a patient's other doctors to provide an extra
layer of support. It is appropriate at any age and at any stage in a serious illness and
can be provided along with curative treatment

FIGURE 1. Center to Advance Palliative Care (CAPC) definition of Palliative Care (www.capc.org/building-a-hospital-based-
palliative-care-program/case/definingpc).

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 Supportive care

Table 1. Search algorithm Four authors provided alternative definitions of

‘curative treatment’ by using free text. None of
# Search the authors chose answer 4 or 6 as their understand-
1 ‘‘palliative care’’[title/abstract] ing of ‘curative’.
2 ‘‘palliative care’’ [MeSH]
3 ‘‘palliati’’[title/abstract] DISCUSSION
4 hospice[title/abstract]
Some definitions of palliative care, such as the
5 1 or 2 or 3 or 4
understanding provided by the WHO [1] (the newer
6 Curati[title/abstract] definitions, Fig. 3) or the CAPC (Fig. 1), advocate
7 5 and 6 palliative care parallel to ‘curative’ treatment. Other
8 neoplasms[MeSH] or neoplas[All Fields] or cancer publications or recommendations, such as the
[All Fields] or oncolog[All Fields] or tumo[All Fields]) definition of the European Association of Palliative
9 7 and 8 Care (EAPC), use the term dichotomously: ‘Pallia-
10 heart[MeSH] or heart[All Fields] tive care is the active, total care of the patient whose
11 pediatrics[MeSH] or pediatric[All Fields] disease is not responsive to curative treatment’ [5].
12 10 or 11 In these definitions, the authors do not clearly
13 9 and not 12 specify whether (in their view) ‘curative’ interven-
14 humans[MeSH] and (English[lang] or German[lang]) tions aim at complete eradication of disease, at
15 ‘‘2002/10/02’’[PDat]: ‘‘2012/09/28’’[PDat])
prolongation of life or rather at any modification
of the disease progress.
16 13 and 14 and 15
Most palliative care recommendations for can-
cer patients and systematic reviews evaluating the
effect of palliative care report studies that assessed
&&
there were no authors listed. These four hits were patients with incurable disease [2 ,9,10]. These
excluded from the list. Thus, together with the authors seem to use the term ‘curative’ if ‘eradica-
NCCN authors, 132 authors were identified in total. tion of the disease’ is the therapeutic goal, but this is
In 25 of those, the current e-mail address was not precisely defined in the publications [6,7]. The
untraceable, so that a total of 107 authors were majority of authors contacted by our working group
contacted by e-mail. The response rate was 39% understand ‘curative’ treatments as aiming at com-
(n ¼ 42). plete cure (absence) of the disease. These respond-
The distribution of answers is shown in Fig. 2. ents declined the use of ‘curative’ as a synonym for
The vast majority of authors chose answer 1 (n ¼ 24). ‘disease-modifying’ or ‘life-prolonging’, or, as one

10% Answer 1: Cancer directed

interventions aimed at complete
absence of disease for the rest
10% of life

Answer 2: Cancer directed

interventions aimed at complete,
durable remission lasting at least
5 (-10) years

9% Answer 3: Cancer directed

interventions aimed at
prolonging life
57% Answer 5: Cancer directed (disease
modifying) interventions regardless
of the aspired therapeutic goal

14% Answer 7: Free text

FIGURE 2. Relative frequencies of answers (rounded).

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Disease-modifying therapy
(curative, life-prolonging or palliative in intent)
Presentation/ Illness
diagnosis
FIGURE 3. World Health Organization’s understanding of palliative care. Reproduced with permission [1].
author explained in an e-mail: ‘Cure, by definition,
involves eradication of the cancer, and not just
prolongation of survival’.
If one agrees with this understanding of ‘cura-
tive’ treatments, this necessitates a closer look at the
current palliative care definitions:
Either palliative care is also indicated for
patients in whom complete absence of the disease
is the therapeutic aim or the authors of many pal-
liative care definitions have a different understand-
ing of ‘curative’ treatments.
Our study reveals significant heterogeneity in
the understanding of the meaning of ‘curative’.
A relevant number of authors understand the
term ‘curative’ differently, including perspectives
that understand a ‘curative’ intervention as a
cancer-directed intervention aiming at prolonging
life or even independent from the aspired thera-
peutic goal. This is particularly important as
palliative care reaches out for being integrated
early in the disease trajectory, so that it might be
in fact applicable for those patients in need even
when there is still a chance for complete eradica-
tion of disease and cure. If then, the term ‘curative’
is also used for disease-modifying interventions in
incurable disease, such a diverging understanding
of the therapeutic goal of ‘curative’ treatments
will pose a persisting source of severe misunder-
standings in interdisciplinary oncology and pallia-
tive care communication. This is particularly
relevant for the everyday clinical setting (e.g.
case conferences and tumor boards). Moreover,
such terminological confusion renders a common
understanding of documents, such as palliative
(cancer) care guidelines impossible. Thus, this
issue is also highly relevant for palliative care
policy development. From our view, this demon-
strates the need for the development and dissem-
ination of a common understanding of these
highly relevant terms.
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‘Curative’ treatments and palliative care Gaertner et al.
Palliative care
Bereavement care
Death
Limitations of this survey
As our goal was not a sensitive search but rather to
obtain a broad overview, we limited our search to
Medline (via PubMed), using a rather narrow
search algorithm.
We hypothesized that especially the oncology
specialists who participated in this survey, as
opposed to palliative care specialists, would have
agreed with answer 1 (eradication of the disease). As
we failed to ask the authors to provide information
about their medical specialization, we are unable to
prove this assumption.
CONCLUSION
Though most authors agree that ‘curative’ treat-
ments aim at absence of the disease, others disagree.
This may be a major source of misunderstandings
when communicating about potential treatment
options for patients with incurable and life-limiting
diseases. We advocate that clinicians, researchers
and policy makers should agree on the definition
chosen by the majority of authors (complete
absence of the disease for the rest of life). Moreover,
curative and disease-modifying therapies should
not be used synonymously as the latter may also
aim at prolongation of life, alleviation of suffering
or both.
Acknowledgements
This study was conducted without funding. The clinical
and scientific work of the Departments of Palliative Care
Freiburg and Göttingen are supported by the German
Cancer Aid (Deutsche Krebshilfe e.V.). The Competence
Center Palliative Care, Baden-Württemberg is supported
by a government grant of the state of Baden-Württemberg.
Conflicts of interest
The authors declare no conflicts of interest.
www.co-oncology.com 383
 Supportive care

REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. World Health Organization. Palliative care. Geneva: WHO Press; 2007 ;
p. 62.
2. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology
&& provisional clinical opinion: the integration of palliative care into standard
oncology care. J Clin Oncol 2012; 30:880–887.
For patients who are not treated in a curative intent, Smith et al. identify three ‘key
tenets’ of palliative care: ‘open and honest communication, medically appropriate
goal setting and symptom management’. For communication and goal setting,
precise wording (as discussed in this article) is essential.
3. Hui D, Mori M, Parsons HA, et al. The lack of standard definitions in the
supportive and palliative oncology literature. J Pain Symptom Manage 2012;
43:582–592.
4. Quill TE, Abernethy AP. Generalist plus specialist palliative care – creating a
& more sustainable model. N Engl J Med 2013; 368:1173–1175.
Quill and Abernethy discuss that all physicians should acquire general palliative
care expertise to care for patients who are not treated with curative intent.
5. Radbruch L, Payne S. White Paper on standards and norms for hospice and
palliative care in Europe: part 1. Eur J Palliat Care 2009; 16:278–289.
6. National Comprehensive Cancer Network (NCCN). Clinical practice guide-
lines in oncology: palliative care. Fort Washington, PA: NCCN; 2012.
7. Kaasa S, Klepp O, Hagen S, et al. Treatment intention in hospitalized cancer
patients in oncological wards in Norway: a national survey. Cancer Treat Rev
1996; 22 (Suppl. A):33–39.
8. Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society
clinical policy statement: palliative care for patients with respiratory diseases
and critical illnesses. Am J Respir Crit Care Med 2008; 177:912–927.
9. El-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for
patients with incurable illness? A review of the evidence. J Support Oncol
2011; 9:87–94.
10. Zimmermann C, Riechelmann R, Krzyzanowska M, et al. Effectiveness of
specialized palliative care: a systematic review. JAMA 2008; 299:1698–
1709.

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