Ms J is a 48-year-old woman with a history of metastatic breast cancer who has been observed in the oncology clinic for 8 months. She was initially diagnosed with locally-advanced breast cancer (hormone-insensitive, HER2-neu–negative) in 2004, for which she received adjuvant chemotherapy and radiation. Her cancer subsequently recurred with lung and bone metastases in 2007. At the time of her original diagnosis, she had been treated at a major university oncology clinic. However, when her metastatic disease was discovered, she had a great deal of suspicion regarding her previous care and felt disaffected by her physicians. Thus, she decided to transfer her care to another institution. The new oncologist’s impression was that, although she had a rather histrionic personality, she was still able to cope with her new situation and make choices appropriately. Her past medical history was otherwise benign, and there was no evidence of any compromised capacity for decision making. Unfortunately, at the time of her recurrence, she was noted to have spinal cord impingement requiring emergent radiation therapy. After a course of palliative radiation, she was administered multiple chemotherapeutic agents, none of which induced a response or stabilization of disease. Although she completed two courses of palliative chemotherapy (sequential docetaxel then capecitabine) with few complications, a primary complaint of fatigue did impact her quality of life to the point that she requested a treatment break. Unfortunately, her course on expectant observation was interrupted by the development of brain metastases, for which she completed whole-brain irradiation. However, her disease and radiation left her with residual rightsided weakness, further deteriorating her quality of life. After completing radiation, she returned to the clinic to discuss the reinitiation of systemic therapy because her performance status had sufficiently recovered to consider palliative chemotherapy. After discussing the merits of third-line chemotherapy in detail, the question to Ms J was whether she wanted to continue on a treatment break or restart therapy. As the query hung in the air with an unpalatable staleness, her silence gave evidence to her struggle in deciding the next course of action. Finally, with deliberate gravity, she said she just did not know what to do. She could not reconcile the low response rate, especially in view of her past experience with cytotoxic therapy, and its associated risk of adverse effects, with her slowly improving but still-limited performance status. She said her quality of life was relatively good, yet she was aware that this would not last long and so she wanted to try something. She just was not ready to make the decision at that point in time. Her oncologist encouraged her that this was reasonable, and that she could take some more time to mull it over as the aftereffects of her radiation continued to wear off. She was scheduled to return in several weeks to review her thoughts and her decision regarding restarting treatment. Three appointments later, over the course of the next 6 weeks, still had not produced a decision. At each appointment, her physicians reviewed the risk of toxicity and the potential benefits of cytotoxic treatment, and each appointment ended the same way: “I’m just not sure.” It was made clear to her that not being treated was reasonable or that a drug holiday, especially in view of her difficult course, was also a sound choice. Alternatively, she could choose to start treatment with agents that have a lower risk of adverse effects, such as gemcitabine or vinorelbine. But Ms J would make neither decision. She uncomfortably straddled the fence, with the associated anxiety of an unclear future. Her caregivers sought to involve her family in her care, however her relationship with her immediate family was somewhat strained, for unclear reasons. Therefore, she would not allow her extended family to provide the support she may have needed to arrive at a decision. As a single mother with one young son, her competing hopes were to stay alive as long as possible while remaining as functional as possible for her child’s sake, not unlike many patients in a similar situation. Yet, this duality in her mind only further complicated her agonizing decision-making process. At her last appointment, the oncologist pointed out that by not making a decision, the choice was being made for her, essentially a course of no treatment. It was then that she revealed that worse than her fear of chemotherapy was a far JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 13 MAY 1 2008