Choosing Not to Treat: How Do You Know When the Best Treatment is No Treatment?
Expert Perspectives · Keira Smith · 2026-04-02
In oncology, progress has long been measured by how effectively we can treat disease. But what happens when the best course of action is not to treat at all? In this episode of Oncology Unfiltered, Melissa Cutrona, Co-Founder and General Manager of i3 Health and Oncology Data Advisor, speaks with Dr. Matthew Hadfield, Oncology Data Advisor Editor in Chief, about the nuanced decision to forgo treatment and how it can reflect a deeply thoughtful, evidence-based, and patient-centered approach.
The Evolving Complexity of Treatment Decisions
Over the past two decades, the shift from traditional chemotherapy to targeted therapies and immunotherapy has made the decision to forgo treatment more complex. “There are certain cancers where despite very severe disease and a very frail patient, you can potentially treat them with something that has minimal toxicity and incredible efficacy,” Dr. Hadfield explains. “But for some patients, the potential benefit of a therapy that may or may not provide minimal amounts of time is not worth the debilitating side effects.”
Because of these advancements, clinicians must now carefully integrate molecular data and patient factors into every decision. “Now, in 2026, we have to really understand the disease, the molecular landscape, and how the cancer should be treated, and then tie that into the patient's overall functioning,” he adds.
Quality of Life as a Central Consideration
When the potential clinical benefits of a therapy are minimal, the impact on a patient's daily life becomes the primary factor in the decision-making process. “Quality of life is among the most important things to consider,” Dr. Hadfield underscores, noting that the tradeoff can be steep. “Unfortunately, after multiple lines of therapy, the options become less and less, the potential benefit becomes less and less, and the toxicities can be significant,” he explains. “And it’s not just the side effects that the therapies introduce; it's also coming to clinic, getting blood draws, getting procedures, and getting biopsies. Sometimes, patients decide that they don't want to do any more treatment, that they want to focus on quality of life and spending their time in a meaningful way.”
Reframing “Doing Nothing”
A significant barrier to patient-centered care is the cultural perception that declining systemic therapy is equivalent to surrendering. “The fight against cancer naturally predisposes people to mistakenly believe that if you don't pursue therapy, you have stopped fighting, you've given up, or you've lost in some way, and that could not be further from the truth,” Dr. Hadfield emphasizes. Choosing not to treat is often a proactive decision to avoid the cumulative burdens of medical intervention.
Navigating Family Dynamics and External Pressures
Oncologists often find themselves in the middle of difficult family disagreements where loved ones may push for continued treatment against the patient's wishes. “You're walking right into their lives, and you don't know the dynamics of their relationships,” Dr. Hadfield notes. In these moments, the clinician’s role is to act as an anchor for the patient. “The most important thing is to remain calm and keep trying to bring conversations back to the patient.”
He recalls a patient who successfully voiced her desire to stop care despite her family's hesitation. “She put her hand on her husband’s wrist and was like, ‘It's okay. It's okay.’ She was saying, ‘I'm ready to go, and we don't have to worry about these things anymore.’ She told us exactly what she wanted, and she was able to voice exactly how she felt.”
Prognostic Uncertainty
While modern medicine has seen "miracles" where patients have profound responses to new drugs, the inherent uncertainty of cancer makes honest communication about the future essential. “At the end of the day, we don't know for sure how a treatment will work. Obviously, no one knows, and that's really hard and it's very unsatisfying for patients,” Dr. Hadfield notes. “But when you have those conversations about prognosis or treatments, being as transparent and honest as you can be is the most important thing.”
To help families navigate this uncertainty, he uses a framework based on the rate of a patient's decline. “If you've been declining over weeks, you likely have a prognosis of weeks to months. If you've been declining over months, you likely have months to a year. It helps them get a north star for which way the trajectory is going.”
Clinical Tools to Guide Decision Making
Clinicians use specific metrics to identify which patients are unlikely to tolerate or benefit from further systemic treatment. “Performance status is something that we talk about quite a bit. It's essentially a gauge of how much someone is up and around and moving versus in a recliner or a bed all day,” Dr. Hadfield explains. “Generally, a lower performance status correlates with doing worse with treatment.”
Beyond functional status, a patient's underlying health determines their "reserve" for handling complications. “If someone has heart failure, diabetes, and hypertension, they don't have a lot of reserve to deal with toxicities if they were to happen on chemotherapy. Essentially, the more fit and healthy you are, the more likely you are to do well in terms of therapy and vice versa.”
The Role of Palliative Care
Palliative care is frequently underutilized because it is incorrectly viewed as being identical to end-of-life hospice care. “I think people often think of palliative care as synonymous with hospice, which is synonymous with dying, but they're very different things,” Dr. Hadfield clarifies. “Palliative care is essentially supportive care.”
He emphasizes that this specialty enhances the treatment journey. “There’s a multitude of studies showing that people who have palliative care involved actually have a longer life expectancy, because they have other physicians supporting them in terms of pain management, nutrition, and sleep.” Because of this, he typically refers metastatic patients to palliative care as soon as he meets them.
Supporting Clinicians in Difficult Conversations
Having these emotionally taxing conversations is a skill that requires deliberate practice and institutional support. “I think the reality is that we all could improve; everyone could get better and serve our patients better,” Dr. Hadfield says. He advocates for institutions to provide resources for communication training. “Generally speaking, when you practice a conversation in front of your peers, it feels embarrassing, but it actually is very beneficial. Those exercises improve your communication skills and your ability to communicate with patients and their families.”
Key Takeaways
Choosing not to treat can be appropriate care: Forgoing treatment is not equivalent to giving up, but rather a valid, patient-centered clinical decision in the right context.
Quality of life should guide decisions: When expected benefits are limited, the impact of treatment on a patient’s daily life, independence, and long-term health becomes the priority.
Treatment decisions are increasingly complex: Advances in targeted therapy and immunotherapy require careful consideration of disease biology, molecular data, and individual patient factors.
The patient’s voice must remain central: Clinicians should consistently refocus discussions on the patient’s preferences, especially in the setting of family or external pressures.
Transparency is essential in uncertainty: Honest, clear communication about prognosis and potential outcomes helps patients and families make informed decisions.
Palliative care is a critical support system: Early integration of palliative care improves symptom management, supports decision making, and enhances overall patient care.