Robert was referred to me by a head and neck surgeon for treatment of what appeared to be stage IV angiosarcoma. He was an articulate and soft-spoken, 82-year-old, fit, retired engineer and pilot with a biopsy-proven angiosarcoma of his scalp who had asymptomatic pulmonary nodules, presumed to be metastatic (Figs 1A and 1B). The primary tumor on his right occiput covered a large surface area but was mostly flat with irregular borders and purple discoloration (Fig 2A). I have been burned often enough in my career that I try never to say a patient has stage IV disease based on imaging alone. I sent him to an interventional radiology colleague for a computed tomography (CT)–guided lung biopsy. Interventional radiology ordered a prebiopsy CT to identify the safest lung nodule for biopsy. Lo and behold, the prebiopsy CT scan showed significant shrinkage of the pulmonary nodules seen on the earlier staging chest CT. Because he had not yet started treatment, this spontaneous shrinkage suggested an inflammatory etiology.

FIG 1. Photomicrograph of patient's scalp (November 20, 2018) biopsy using hematoxylin and eosin staining: (A) ×20 magnification and (B) ×400 magnification.

FIG 2. (A-C) Photographs of the patient’s scalp in chronologic order, with the oldest photo first. Printed with permission of the patient.

With what now looked like limited disease, I suggested we explore potentially curative local therapies such as radiation or surgical resection. Both radiation oncology and surgery turned him down and suggested I try systemic chemotherapy for this large surface area tumor. I was disappointed because chemotherapy alone is not considered primary therapy for most nonmetastatic sarcomas. Robert and I discussed the natural history of angiosarcoma, the fact that it is relatively unresponsive to chemotherapy, and that chemotherapy is usually used as an adjunct but not as primary therapy for unresected tumors. We talked about the quality of Robert’s life and his goals of care. I learned he was the sole caregiver for a spouse with multiple medical conditions, including frailty, and that he still built and flew experimental planes. We reviewed the common adverse effects of chemotherapy and discussed how they might interfere with his current life goals, his ability to care for his wife, and his ability to live independently. He was willing to undergo the rigors of radiation or surgery because they offered short-term toxicity and the chance of cure. I was reluctant to recommend a course of treatment to this vital, asymptomatic man that would likely make him tired, unable to eat, prone to infections, and possibly unable to enjoy his usual activities or drive, all with no guarantee of cure. He agreed with me. We discussed palliative care, but he had no symptoms to palliate. We discussed hospice, but he wanted cancer-directed therapy, just not yet. So neither palliative care nor hospice referrals were appropriate at the time. We made a shared and informed decision to monitor his tumor closely, with plans to treat if and when there was evidence of disease progression. He felt that he would be more willing to accept the adverse effects and limitations inflicted by chemotherapy if or when he experienced progression. I also made him aware of the fact that once it has spread, his sarcoma might be incurable, and he was willing to take that chance. We took measurements of the tumor and photographs to document its progress.

Over the next 3 months, we happily noted the absence of any signs of progression. We switched to every-other-month visits. By the fifth month, he thought his tumor was diminishing in area and the one nodular area was flattening out (Fig 2B). I agreed. I grilled him about whether he was using topical chemotherapy, seeing another oncologist, or using compound X (a popular Wyoming “natural” cancer therapy), but he assured me he was doing nothing other than shaving his scalp and taking a monthly photograph. During each subsequent visit, the involved area shrank and became lighter in color while I continued to ask him about use of any complementary topical or systemic therapies. By 11 months, it was nearly gone—not palpable and barely visible. At 15 months, with only tincture of time as therapy, his large angiosarcoma was not visible (Fig 2C). At his last visit, we reflected on the possible causes of what appeared to be spontaneous tumor regression and whether the initial diagnosis was correct. We laughed about the fact that, had I treated him, we would both be attributing the disappearance of tumor to treatment efficacy. We were more somber when we reflected on the probability that we would next have labored over the decision to continue maintenance therapy or stop treatment. I related cases of melanoma and kidney cancers that regressed without treatment, or spontaneously. I shared with him the wish of many patients for miracles and the rarity of such miracles in real life. We acknowledged we were in uncharted territory. “Maybe we’ll never know doc, but I sure am glad you didn’t treat me. Why don’t you write that up for one of your journals?” And here I am, following my patient’s instructions, completing my “assignment.”

It is difficult to choose observation in a culture that is action driven, where the term do-nothings is a pejorative noun, where the treatment of cancer is couched in military terms (the “war against cancer”) and engagement in treatment is an act of bravery, and where more (more tests, more scans, more intensive treatment) done sooner is perceived as better. As with most patients with cancer, Robert initially came to me expecting treatment of his cancer, albeit what he believed to be stage IV cancer. And like most practicing oncologists, I have confidence in the ability of the therapies in my tool box to shrink tumors and prolong life. So why did patient and physician both choose no treatment? I think with the foundation of a good relationship and open communication, we were able to explore what was available therapeutically and what was important to the patient and to collaboratively decide that doing nothing at that moment was the best decision for him. We reframed it as “do nothing now, be prepared to act when necessary.”

But why was I comfortable with observation only when I am in an action-driven profession? From my perspective, although advanced in years, Robert had an excellent performance status that did not preclude chemotherapy, even at age 82. I have a healthy respect for treatment adverse effects, however. In my mind, a toxic systemic therapy for localized disease, particularly disease not known for chemotherapy responsiveness, was neither evidence-based nor high-value care. And why was the patient comfortable with no treatment? Listening to and learning from Robert that his goals of care were not to do “everything possible to eradicate tumor” but to “maintain the highest functionality of each day” allowed me to lay the foundation for an honest, open discussion about the realistic costs of chemotherapy treatment and the likelihood of success. We knew that chemotherapy toxicities were not compatible with his goals of care. He recognized that we were risking spread of this tumor, but he also recognized that the preferred local options were not being offered to him. Having considered all these angles, we agreed to treat him with tincture of time. We were both aware of the risks of this choice, primarily that the tumor could spread and become incurable. However, we were confident that this choice would be most compatible with achieving his life goals and that we could initiate palliative chemotherapy should it become necessary. He has spent the past 16 months in his home, driving, caring for his wife, visiting grandkids around the country, and enjoying life! We talk about miracles in medicine, but we don’t see too many of this magnitude. I count this as one of the rare miracles in oncology. I hope it will last and will wish it on many other patients.

When a patient is referred to me for treatment, I feel I may disappoint the patient or referring doctor by offering observation instead of treatment. Yet, when I probe, many patients are happy to have their doctor support a watch-and-wait approach. For these patients, the choice to accept an offered treatment, with all its attendant toxicities, may be driven more out of fear of disappointing their doctor or family members than by wholehearted acceptance of the treatment. What I learned through Robert was that sometimes the best thing I can offer my patients is not the cutting-edge treatment but the information, encouragement, and support to choose no active treatment. Taking the time to find out what a patient really wants, and then acting on it, may be the best gift or service we can provide to our patients with cancer. Robert and his wife certainly felt so. Robert expressed his wishes, and I honored those wishes. His mind, his immune system, or some higher power produced a spontaneous regression of his tumor. And voilà, we have a modern-day miracle. Although the miracle of spontaneous tumor regression is not in the hands of an oncologist and even the miracle of offering more time on earth often eludes an oncologist, I believe the miracle of providing quality time is in the hands of every oncologist with listening ears and a feeling heart.