Quality of Life vs. Length of Life? Pick One.

by Carolyn Thomas    ♥    Heart Sisters (on Blue Sky) 

Even as a fairly new breast cancer patient (diagnosed with invasive ductal carcinoma on April 1st, 2025), I knew I’d likely choose quality of life (QoL) over length of life (LoL) after my diagnosis.

As U.K. researchers reported in the medical journal Psycho-Oncology (1): 

“A diagnosis of cancer can be devastating. Deciding on the appropriate treatment can be complicated and daunting. Patients are asked to make decisions which require patient understanding of treatment choices, including all potential benefits and harms.”

Whaaaat?     “Patients are asked to make decisions about their treatment plan?!” 

 What I recall in those overwhelming early days was being handed a 6-page typed treatment plan that described 17 rounds of chemotherapy and/or immunotherapy drugs to be drip-drip-dripped into my body every three weeks for 4-6 hours. Even the very useful  BreastCancer.Org  site does not mention asking patients to make cancer treatment decisions. Here’s what they say instead: 

“After a breast cancer diagnosis, and based on your pathology report, your doctors will put together a specific treatment plan made up of one or more cancer treatments, each intended to target cancer cells and also reduce the risk of future breast cancer recurrence.”

I often mentioned to family and friends in those early days that my treatment plan felt like being on an endless conveyor belt. My only role was to jump onboard whenever told to do so  – while desperately trying not to fall off. 

Meanwhile those U.K. researchers suggested that how treatment plans are currently decided may differ now from in the past. For example, they included this historical perspective: 

“The primary focus of cancer treatment has always been to increase overall survival (length of life).  But quality-of-life has been increasingly recognized as an important end point.” 

 The U.K. research included literature reviews of academic papers published between the years 1942-2018. From those studies, they could identify what they called the “complex trade‐offs” which make cancer patients choose quality over quantity of life (or vice-versa). For example: 

• Older age (which may be linked to declining physical status) was associated with a preference for quality of life over length of life.
• Younger patients were more likely to undergo aggressive treatment to increase survival years.
• Preference for either quality or quantity of life was not influenced by gender, education, religion, having children, marital status or type of cancer.
• Patients in better health generally valued length of ife,  and inversely, those in poorer health valued quality of life. 

The first time I dared to question the terms of what I believed was my carved-in-stone treatment plan happened because my own experience of suffering through brutal chemotherapy side effects had simply become unbearable to me. I was one week away from starting Chemo Day #4, and I knew what was coming.

So I asked my oncologist: “What other treatment options are available to me in the future?”  To my great relief, he offered two options that might help to reduce my suffering: one was to postpone my next Chemo Day for a week or so to give my body a wee break, and the second was to slightly reduce the dosage of my chemotherapy drugs. The fact that these chemotherapy drugs had already produced significantly positive results likely encouraged his decision to revisit my treatment plan. The combination of both options meant a remarkable quality-of-life improvement after the next ChemoDay – but the most amazing part of this experience was that, until that moment, I was unaware that a cancer patient was able to even request a change to a cancer treatment plan. Who knew?  

One of the common chemotherapy side effects at the time was called Hand-Foot Syndrome, an awful condition in which cracked peeling blisters appear on the soles of both feet. I was watching the skin on my heels falling off in alarming chunks. Because every step was so painful, my oncologist’s staff arranged the loan of a walker from the Red Cross to help me move about. At about the same time, another bizarre (yet very common) chemo side effect struck:  everything I ate or drank – including water – tasted disgustingly metallic. I basically lived on ginger ale, frozen popsicles and protein shakes. I had to reflexively spit out every bit of solid food I tried putting into my mouth. 

So within one single week,  I couldn’t walk and I couldn’t eat. To me, that felt like the very definition of a poor quality of life. 

At that time, I was unaware of something called “late effects of cancer treatments”.  Mayo Clinic oncologists explain how this happens: 

“Cancer treatment may be over, but the side effects of treatment can continue. The treatments that may have saved your life may also cause side effects going forward. And as more people live longer after cancer treatment, more is being found out about late side effects. Cancer survivors might have late effects of cancer treatment years later. It isn’t clear that late effects can be prevented, or why some people might experience late effects while others don’t.” 

So are cancer specialists actually telling us: “We do not know if our treatment plans are going to seriously harm our patients longterm, even – after we have stopped their treatments – but we’re going to keep recommending those treatments anyway”?

I’ve been quoting the wisdom of the late cardiologist (and Nobel Peace Prize winner) Dr. Bernard Lown for several years, especially from his inspiring book, The Lost Art of Healing: Practicing Compassion in Medicine.  I’m quoting him here today because he often used these provocative words on the topic of minimizing the suffering of patients:

“Doctors may justify their ill-doing by their well-meaning.”

Think about that statement. No doctor wakes up in the morning aiming to deliberately cause pain or suffering in their cancer patients. Doctors devote their entire careers to help sick people – yet so much of cancer care seems to reinforce Dr. Lown’s statement. And personally, I’m only short months into what could be a long road of future cancer treatments – including my mastectomy surgery scheduled for November 25th – and already I feel like I’ve exceeded my lifetime quota for devastating side effects.  

Some cancer patients, as the U.K. researchers remind us, are willing to endure the known toxicities associated with chemotherapy, for example, in order to increase their length of life, while others value their quality of life far more, and are reluctant to spend their remaining years in a compromised state of health.

One common trade‐off for potential gain in life expectancy may involve a willingness to tolerate short‐term treatment side-effects (e.g. post-surgical pain, chemotherapy‐induced nausea, or hair loss (alopecia). And the compromise is not always restricted to health reasons, but instead may be about financial burdens or increased dependency on friends and family.

 The U.K. research included literature reviews of academic papers published between the years 1942-2018. From those studies, researchers could identify what they called the “complex trade‐offs” which make patients with cancer choose quality over quantity of life (or vice-versa). For example: 

• Older age (which may be linked to declining physical status) was associated with a preference for quality of life over quantity of life.
• Younger patients were more likely to undergo aggressive treatment to increase survival years.
• Preference for either quality or quantity of life was not influenced by gender, education, religion, having children, marital status or type of cancer.
• Patients in better health generally valued length of life,  and inversely, those in poorer health valued quality of life.
• Little information was available regarding patients’ preferences and attitudes toward their cancer treatment and the personal costs they might be prepared to exchange to extend life.

Finally, this U.K. study recommends that, “with cancer treatment and care now becoming more patient-centered, it has become more pertinent to understand the impact of a cancer diagnosis on EVERY patient.”  

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1. Shrestha A, et al.  “Quality of life versus length of life considerations in cancer patients: A systematic literature review” . Psycho-Oncology. 2019 July 28(7):1367-1380.

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Q:  Quality vs. quantity of life: which matters more to you?

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NOTE FROM CAROLYN:   In my book, “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press), I wrote more about the late cardiologist Dr. Bernard Lown’s legacy  – no matter the diagnosis. You can ask for this book at your local library or bookshop (please support your favourite independent booksellers!)  or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press. Use their code HTWN to save 30% off the list price when you order.