We are adding only harm to patients already cured
In the pursuit of preventing cancer's return, medicine has long accepted a quiet bargain: treat many to help a few, and absorb the harm done to those who needed nothing at all. A new study presented at ASCO by Elizabeth Nally, and amplified by oncologist Charles Jiang, turns the lens toward that hidden cost — asking not only whether adjuvant pembrolizumab works in renal cell carcinoma, but whether patients who received it felt it was worth it. It is a question that sounds simple and is, in fact, among the most difficult in medicine.
- Every patient who undergoes adjuvant immunotherapy after kidney cancer surgery belongs to one of three groups — cured, incurable, or genuinely helped — yet oncologists have no way to tell them apart before treatment begins.
- Patients already cured by surgery spend a year in active cancer treatment, absorbing fatigue, autoimmune side effects, and financial strain for a disease they no longer have.
- Elizabeth Nally's research breaks from the clinical norm by measuring decision regret and patient-perceived toxicity — capturing what standardized trial forms routinely miss about the human experience of treatment.
- Charles Jiang's endorsement signals a growing discomfort in oncology: expanding who gets treated, and how early, without expanding how harm is measured, risks dressing up burden as benefit.
- The field is being asked to hold two truths at once — that adjuvant pembrolizumab saves some lives, and that it costs others something real — and to build the tools to finally tell the difference.
Charles Jiang, a medical oncologist at UT Southwestern, recently drew attention to research by Elizabeth Nally, a specialist registrar at Barts Health in London, who presented findings at ASCO on decision regret and toxicity perception among patients who received adjuvant pembrolizumab after surgery for renal cell carcinoma. It is the kind of study that rarely makes headlines, but it addresses something oncologists quietly reckon with every day.
The core problem is this: when a surgeon removes a kidney tumor, the decision to add immunotherapy afterward applies simultaneously to three distinct groups of patients. The largest group is already cured — surgery was enough. A second group will develop metastatic disease regardless of any additional treatment. Only a third, smaller group carries microscopic disease that the drug might actually eliminate. The benefit belongs entirely to that third group. The other two absorb the toxicity, the cost, and a year of their lives spent as active cancer patients — for nothing.
Nally's research approaches this from the patient's side rather than the clinician's. She examined whether patients felt they had made the right choice, and how they experienced the side effects themselves — because a year of fatigue that disrupts work and family life is not the same as a data point on a standardized scale. What clinical trials record as manageable can feel entirely different to the person living through it.
Jiang is not arguing against adjuvant therapy. He is arguing for honesty about its hidden arithmetic. As oncology pushes toward earlier and broader treatment, studies that measure harm from the patient's perspective are what keep the field from treating everyone more aggressively simply because it has become possible to do so. The question Nally is asking — at what cost does this benefit come, and for whom — may be the most important one the field is not yet equipped to answer.
Charles Jiang, a medical oncologist at UT Southwestern Medical Center, recently amplified a colleague's research on a question that sits at the heart of modern cancer treatment: how do we know when we're helping, and when we're simply adding burden to people who didn't need it?
The work in question comes from Elizabeth Nally, a medical oncology specialist registrar at Barts Health in London, who presented an abstract at the American Society of Clinical Oncology conference examining decision regret and toxicity perception in patients who received adjuvant pembrolizumab—an immunotherapy given after surgery for renal cell carcinoma to prevent recurrence. It's the kind of study that doesn't make headlines, but it addresses something oncologists live with every day: the uncomfortable arithmetic of adjuvant therapy.
Jiang's commentary cuts to the core of the problem. When a surgeon removes a kidney tumor, the medical team faces a decision: should they add chemotherapy or immunotherapy to mop up any remaining cancer cells? The trouble is that this single treatment decision applies to three entirely different groups of patients, and the doctors have no way to tell them apart on the day the decision must be made. The first group—often the largest—consists of patients already cured by surgery alone. They will never recur. The second group will develop metastatic disease no matter what additional treatment they receive. The third, smallest group has microscopic disease that the drug might actually eradicate. Only those in the third basket gain anything from adjuvant therapy. The other two absorb all the toxicity, all the cost, and spend a year of their lives in the role of cancer patients, undergoing treatment for a disease they either don't have or cannot escape.
This is not a theoretical problem. Patients in the first two baskets experience real side effects from immunotherapy—fatigue, autoimmune complications, financial strain—and they experience them for no medical benefit. They also experience the psychological weight of extended cancer treatment when they might have been moving forward with their lives. The current tools available to oncologists cannot distinguish between these groups before treatment begins. There is no crystal ball, as Jiang puts it. So every decision to treat earlier, to treat longer, or to expand the population eligible for adjuvant therapy carries the same hidden cost: some patients will be harmed in the pursuit of helping others.
Nally's research approaches this problem from a direction that has historically received less attention in oncology: she measured it from the patient's perspective rather than from the clinician's. She looked at decision regret—whether patients felt they had made the right choice—and at how patients themselves perceived the toxicity they experienced. This matters because what looks like a manageable side effect in a clinical trial, recorded on a standardized toxicity scale, can feel entirely different to the person living through it. A year of fatigue that prevents someone from working or spending time with family is not the same as a checkmark on a form.
Jiang's endorsement of this work carries weight because he is not arguing against adjuvant therapy or against immunotherapy. He is arguing for honesty. As the field pursues better treatments and earlier interventions, studies that measure harm from the patient's side—not just from the clinician's side—are how oncology stays grounded in reality. They are how the field avoids the trap of treating everyone more aggressively simply because it is possible to do so. The conversation around adjuvant pembrolizumab in renal cell carcinoma is shifting, and it is shifting because researchers like Nally are asking the question that matters most: at what cost does this benefit come, and for whom?
Notable Quotes
Studies that measure harm from the patient's side rather than the clinician's side are how the field stays honest as it chases cure.— Charles Jiang, Medical Oncologist at UT Southwestern Medical Center
Our work contributes to the important conversation around long-term toxicity, quality of life and patient experience following adjuvant immunotherapy in renal cell carcinoma.— Elizabeth Nally, Medical Oncology SpR at Barts Health
The Hearth Conversation Another angle on the story
Why does it matter that Nally measured toxicity from the patient's side rather than the doctor's side?
Because a clinician filling out a toxicity form and a patient living through a year of exhaustion are describing different realities. The form says "grade 2 fatigue." The patient says "I couldn't work." One gets recorded in a database. The other shapes whether someone feels their treatment was worth it.
But if adjuvant therapy can cure some patients, doesn't that justify treating everyone?
Only if you're willing to accept that some people will be harmed unnecessarily. The problem is we can't tell in advance who will benefit and who won't. So we treat three groups at once, knowing two of them gain nothing.
What would change if doctors could identify which patients actually need adjuvant therapy?
Everything. You'd spare the already-cured from unnecessary toxicity. You'd spare the destined-to-recur from false hope and real side effects. You'd concentrate treatment on the people it can actually help. But we don't have that test yet.
Is Jiang saying oncologists are being reckless?
No. He's saying they're working with incomplete information and making the best decisions they can. But he's also saying the field needs to stay honest about what those decisions cost the people who don't benefit.
Why is this study being presented at ASCO, the major cancer conference?
Because patient-reported outcomes are becoming central to how we evaluate whether a treatment is truly an advance. Survival numbers matter, but so does the year you spend getting there.