My mother-in-law, Julie, was diagnosed with stage IV lung adenocarcinoma in September 2023. She had never smoked. She skied, hiked, gardened, and did Pilates well into her sixties. By the time the cancer was found, it had spread through her chest cavity.
The first plan was carboplatin and pemetrexed, the standard chemotherapy backbone for her cancer. It worked for about six weeks before her disease progressed into her lung, liver, and bones.
What changed everything was the molecular profile. Her tumor came back positive for a HER2 exon 20 insertion mutation, found on a Tempus panel ordered up front because we insisted. That one result opened doors standard chemotherapy never would have. She qualified for Enhertu, a HER2-directed antibody-drug conjugate. When that progressed, she qualified for a clinical trial of zongertinib, a HER2-selective targeted therapy that has since received FDA approval. Each treatment bought her time. Time to enjoy one more summer, to sit at the table with her family, to know her grandchildren a little longer.
Julie passed away last year.
We built this patio in memory of Julie, a place for gathering, deep conversation, and the kind of ordinary magic she loved most.
Standard chemotherapy gave her six weeks. The targeted therapies opened by that one molecular test gave her sixteen more months. Every time a new patient sits down with metastatic disease, I think about her.
Most oncology appointments are structured to deliver a plan, not to interrogate whether the plan is the right one. When your oncologist walks in, they already have something in mind for you. That is not a criticism. It is how the system runs. But harder questions make better medicine, and you are allowed to ask them.
A written question list is the single highest-leverage thing you can bring into that room. Amid some of the most overwhelming moments of anyone's life, a list keeps you on track. Here my list:
On the diagnosis
Help me understand cancer. I know this sounds like an odd question. You know what cancer is... But do you really understand what that means?
Before making decisions about treatment, ask your oncologist to explain how your cancer forms, grows, spreads, interacts with the immune system, and sustains itself. Understanding the biology of your disease makes every conversation that follows easier to navigate and every treatment decision easier to understand.
What is the exact name of my cancer, including subtype and any mutations found so far?
Has my tumor been sent for comprehensive genomic profiling? If not, can it be ordered now, not later? And can it be repeated at progression, since tumors change?
Given my cancer type and history, should I also have germline testing? Some mutations that look somatic are actually hereditary. This matters for your family and sometimes for your treatment options.
What is my stage, and what does that actually mean for treatment and prognosis?
On the treatment
What is the goal here: cure, prolonged remission, or symptom control? Be direct with me.
Why this regimen for someone with my exact molecular profile? Is this guideline-based or is there a better fit?
Are there targeted therapies, immunotherapies, or clinical trials that match my mutation status? Have you checked TrialSpark or the NCI’s trial matching tools, or do you have someone who does that?
What are my alternatives, including doing less than you are recommending? Different drugs, lower doses, less frequent dosing?
Has my case been reviewed by a tumor board, and if not, is that something we can do?
On side effects and preparation
Which side effects are most likely, and which should make me call the same day?
Between now and when treatment starts, what can I do to improve tolerability and response? Are there any prehabilitation strategies you recommend?
What does the evidence say about diet, exercise, and sleep during this regimen? I want specifics, not general wellness advice. If a provider tells you lifestyle modifications will not make a difference in cancer, find a different provider.
On integrative care
Are you open to adjunctive, integrative care? Ask this question directly. The answer tells you a lot.
Do you have an integrative oncology team, or someone you trust to refer me to?
Here is my supplement list. Which would you pause, which are fine, and which do you not have an opinion on? Are the interactions you are concerned about theoretical or established in the literature?
Have you seen any data on metabolic interventions in my cancer type?
Are there any off-label drugs that have shown promise in my type of cancer?
What integrative oncology centers do you know and would consider for a parallel consult?
On monitoring and the long view
How will we know if this is working, and how soon? Will you use imaging alone, or is ctDNA monitoring or liquid biopsy an option for earlier signal?
If this regimen stops working, what is the next line? Is there a plan B and plan C already, or do we figure that out when we get there?
When should I seek a second opinion, and where would you send someone you love?
If the goal is cure, when do we start planning for life after treatment?
Bring this on paper. Hand a copy to whoever is in the room with you, because two memories beat one in a long appointment. Ask the awkward, uncomfortable questions out loud: about goals, about alternatives, about what happens if this does not work. If you run out of time, ask for a follow-up to finish the list. Do not apologize for needing it.
Julie’s story is not unusual anymore. Targeted therapies are expanding across lung, breast, colorectal, gastric, melanoma, prostate, and a growing list of other cancers. The molecular landscape is also shifting. Germline mutations, rare fusions, resistance mechanisms found on liquid biopsy are now informing second and third-line decisions in ways they were not five years ago. No two cancers are the same. The only way to access what fits your tumor is to know what is driving it, and the only way to know that is to ask for the test. Early, and again at progression.
Germline findings also let us tailor integrative interventions, from nutraceuticals and IV therapies to off-label drugs with mechanistic rationale for your specific mutation profile. The molecular data that unlocks your systemic treatment can inform your integrative plan too.
Despite how some medical professionals act, this is not a dictatorship. You are not a passive recipient of a plan someone else made for you. The best oncology care is built on collaboration and trust, and that only works if both people in the room are actually talking. Your questions are not an inconvenience. They are how good medicine gets better.
Ksenia Malarkey, ND is a naturopathic physician specializing in integrative oncology, hormones, and metabolic health.
She provides medical care for Washington residents and offers global health coaching.
To schedule a free 15-minute consult, visit drkseniamalarkey.com
This kind of testing and personalized treatment is where cancer care should be heading. Unfortunately, it remains an exception these days. Still, I think we’ll get there eventually because such tests will get used more and more.
Excellent advice in general for speaking up at various doctor appointments. Thank you