06/18/2026
The words "Stage 4" once meant one thing: prepare to die, quickly. That is no longer the whole story.
A recent New York Times piece profiles Kate Dietrick, a 42-year-old archivist living with metastatic breast cancer for nearly four years. She shops for a gravesite. She watches friends from her cancer support group die. She also plans museum exhibits, hosts Shabbat dinners, and debates whether to buy nice clothes. Her story captures something medicine has quietly produced over the past two decades: a growing population of people who are neither dying soon nor able to plan as if they will live forever.
The statistics reflect genuine progress. More than a third of people diagnosed with metastatic cancer now survive five years or more, compared with 17 percent in the 1990s. New targeted therapies, immunotherapies, and refined treatment regimens have driven this shift. But the numbers, remarkable as they are, still understate what I see in my clinic.
I have patients who are living 15 or more years after a Stage 4 diagnosis. Not in remission. Not cured. Living, working, traveling, loving, and in some cases, outliving the statistics by a decade or more. This is not a miracle. It is medicine working as it should, incrementally and persistently, buying time that compounds into something that looks increasingly like a life.
The psychological terrain, however, has not kept pace. What Kate's story makes vivid is the particular suffering of prolonged uncertainty: not knowing whether to spend savings or preserve them, whether to say goodbye or keep planning, whether optimism is a survival strategy or a form of denial. These are not small questions. They are the organizing questions of a life, and metastatic cancer strips away the usual frameworks for answering them.
As a psycho-oncologist, this is the work I sit with every day. The goal is not to eliminate uncertainty, which is impossible, but to help patients build a relationship with it that allows them to remain fully present in their own lives. That means grieving what is lost. It also means refusing to let anticipated loss consume the time that remains.
Kate puts it plainly: sorting through her possessions in preparation for death, she stopped and thought, "This is bu****it. I'm still alive."
She is right. And more patients than ever have years, sometimes many years, in which to act on that fact.
