The Fault in Our Stars (2014)

Hazel is sixteen. She has thyroid cancer that has spread to her lungs, held stable on an experimental drug, and she carries an oxygen tank.

At a support group she meets Augustus, in remission from osteosarcoma after losing a leg. They fall in love, travel to Amsterdam to meet a reclusive author, and Augustus's cancer returns.

Spoilers throughout. This page says how The Fault in Our Stars ends.

The film is often described as a story about one thing. It is really about two diseases that behave differently, and the difference is the most useful part of it.

The support-group texture is well drawn, including how much the participants resent it. Hazel's oxygen dependence is treated as ordinary rather than as a prop. Her fear of being a grenade to the people who love her is a recognizable version of guilt that carers rarely hear said out loud.

Augustus's path also follows a real pattern. Amputation, remission, then recurrence in the lungs. That sequence is not invented.

The film calls Hazel's treatment Phalanxifor. No such drug exists. The situation it stands in for does.

Thyroid cancer usually behaves well. NCI describes well-differentiated papillary and follicular tumors as highly treatable and usually curable. The standard sequence is total thyroidectomy followed by radioactive iodine, which both clears remaining thyroid tissue and treats metastases. NCI names the lungs and bones as the most common distant sites, and states that treatment of distant metastases is usually not curative but may produce significant palliation.

The fork that matters is whether the metastases still take up iodine. If they do, therapeutic doses of iodine-131 can ablate them. If they do not, the disease is called radioiodine-refractory, and drugs take over.

Two are established. In the SELECT trial, lenvatinib taken daily produced a median progression-free survival of 18.3 months against 3.6 months for placebo, with an objective response rate of 64.8% against 1.5%. Overall survival was not significantly different. In the DECISION trial, sorafenib taken twice daily gave median progression-free survival of 10.8 months against 5.8 months. Both are tablets swallowed at home, and both are commonly started or continued below the trial strength because of blood pressure, hand-foot soreness and fatigue, so the amount is one to settle with your own endocrinologist or oncologist.

Both come with a cost the film never shows. Grade 3 or higher adverse events occurred in 75.9% of the lenvatinib group. The common effects were hypertension in 67.8%, diarrhea in 59.4%, fatigue in 59%, appetite loss in 50.2% and weight loss in 46.4%. Sorafenib's most common effects were hand-foot skin reactions in 76.3% and diarrhea in 68.6%.

A teenager on a drug like that is not simply stable. She is tired, hypertensive, and losing weight.

Osteosarcoma is the most common bone cancer in children and young adults, and the film gets its shape right while getting its statistics unspoken.

Augustus loses a leg. NCI reports that in general, more than 80% of people with osteosarcoma of an arm or leg can be treated with a limb-sparing procedure and do not require amputation. Limb-sparing means removing the tumor and replacing bone or joint with a graft or prosthesis. It is planned only when staging suggests wide surgical margins are achievable.

Amputation remains the right choice for some. NCI notes that people who undergo amputation have lower local recurrence rates, but that there is no difference in overall survival between amputation and limb-sparing surgery.

One detail matters early and is easy to miss. NCI stresses that the biopsy should be done by a surgeon skilled in limb-sparing technique, because a badly placed biopsy incision can make later limb-preserving reconstruction impossible.

Both teenagers end up with lung disease, from opposite directions.

For osteosarcoma, that is the expected route. About 20% of people have visible metastases at diagnosis, and 85% to 90% of those are in the lung. NCI reports that overall event-free survival remains about 20% to 30% for metastatic disease at diagnosis. In the EURAMOS trial, 5-year event-free survival for metastatic patients was 28% overall, but 64% for those who achieved a complete surgical remission at all sites within 3 to 6 months, with overall survival of 79%.

Response to chemotherapy is measured in tissue, not on a scan. Pathologists assess necrosis in the removed tumor, and 90% or more predicts a better outcome than less than 90%.

The most practical thing this film points at is a symptom that gets dismissed constantly.

Osteosarcoma's usual first sign is bone pain, often worse at night or with activity, sometimes with swelling near a joint. Growing teenagers ache all the time, which is exactly why it gets missed. Pain that is persistent, fixed in one place, worse at night, or paired with swelling deserves evaluation.

Location helps. About half of osteosarcomas arise in the femur, and 80% of those in the distal femur, just above the knee. The next most common sites are the proximal tibia, proximal humerus, pelvis, jaw and fibula.

Thyroid cancer announces itself differently, usually as a painless neck lump. NCI notes that a nodule not taking up iodine on scanning, a so-called cold nodule, carries an overall cancer risk of 12% to 15%.

Both teenagers stay articulate and largely comfortable until very near the end. Real advanced cancer in adolescents involves far more pain management, hospital time and cognitive fog. The Amsterdam trip in Hazel's condition is romantic rather than plausible.

None of that makes the film dishonest. It makes it a film. See screening and possible warning signs for the parts it leaves out.

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This page discusses The Fault in Our Stars for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email corrections@cancerexplained.org.

• NCI PDQ — Osteosarcoma and Undifferentiated Pleomorphic Sarcoma of Bone Treatment (Health Professional Version)
• NCI PDQ — Thyroid Cancer Treatment (Health Professional Version)