- Email: [email protected]
Palliative chemotherapy: a clinical oxymoron
CORRESPONDENCE
Sir—The Collins dictionary1 defines palliate thus: “to lessen the severity of (pain or disease) without curing [it].” The word is derived from Late Latin palliare (to cover up), from the Latin pallium (a cloak). The Oxford Textbook of Palliative Medicine2 defines palliative care as: “the study and management of patients with active, progressive, faradvanced disease for whom the prognosis is limited and the focus of care is on the quality of life”. Chemotherapy can provide palliative benefit, whether the aim of such treatment is cure, prolongation of life, or simply to gain symptom relief. That is, chemotherapy can help to manage troublesome symptoms and can assist in improving quality of life. In patients with advanced or metastatic cancer, chemotherapy can also provide an important survival benefit, as is the case in many diseases—eg, metastatic breast or colorectal cancer. The potential to extend life is a powerful motivation to accept chemotherapy. Results of many studies3,4 suggest that patients with advanced cancer are willing to endure great toxicity for even a small chance of extended survival although patients and clinicians often have quite different views about the potential benefit that might make treatment worthwhile.3 As a guiding principle, treatment goals should always be clearly understood, to ensure appropriately informed decisions.4 An individual patient might choose to have chemotherapy that could extend their life, but choose not to have treatment if the sole aim was to palliate symptomatic disease. It is therefore important to clearly distinguish these scenarios. Unfortunately, the term palliative chemotherapy has been used to decribe both goals. Indeed even reports from meta-analyses5 that have shown chemotherapy to improve survival have described the treatment as palliative. This description confuses the goals of chemotherapy for both patients and for clinicians. We contend that treatments that could extend life should be described as such. Treatments that aim solely to relieve pain might reasonably be described as palliative. Thus, the term palliative chemotherapy should not be used to describe a treatment regimen, the principal objective of which is to prolong survival. *Michael Jefford, John Zalcberg Peter MacCallum Cancer Centre, Melbourne, Victoria 8006, Australia (e-mail: [email protected])
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Anon. Collins essential English dictionary. Glasgow: Harper Collins, 2003. Doyle D, Hanke G, MacDonald N. Oxford textbook of palliative medicine, 2nd edn. New York: Oxford University Press, 1999. Duric V, Stokker M. Patients’ preferences for adjuvant chemotherapy in early breast cancer: a review of what makes it worthwile. Lancet Oncol 2001; 2: 691–97. Haines IE, Zalcberg J, Buchanan JD. Notfor-resuscitation orders in cancer patients— principles of decision-making. Med J Aust 1990; 153: 225–29. Colorectal Meta-analysis Collaboration. Palliative chemotherapy for advanced or metastatic colorectal cancer (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Wellcome Library, London
Palliative chemotherapy: a clinical oxymoron
The role of the surgeon in translational research William B Coley
Sir—In the late 1890s William B Coley (figure), a young surgeon working in New York, noted that the cancers of some of his patients—who routinely died of post-operative infections—had gone into remission after an episode of erysipelas, a streptococcal infectious disease of the skin. In view of this observation he made the development of vaccines against cancer his life’s work. Commenting on Coley’s experiences, one of his colleagues, a radiation oncologist named James Ewing, asserted that since he was a surgeon and not a scientist, his occasional miracle cures were “probably all baloney”.1 Translational research can be defined as, and implies, a bidirectional process (from biology to relevant interventions) and is usually realised by creating a connection between basic and clinical research. Multidisciplinary teams are involved in translational research, and each person’s effort is based on individual skills. The role of surgeons in these teams is marginal, but the impressive step forward in the biological characterisation of cancer as a result of the sequencing of the genome has brought into surgery a multitude of variables with staggering classification potentialities. In lung cancer, surgery is the only method of cure, but seldom is its application with radical intent possible. Surgical behaviour is based on grossly macroscopic evidence, and the tumour node metastasis system determines almost every surgical indication. Despite the efforts aimed at integrating all therapeutic strategies, the overall outcome of the management of the disease remains disappointing and the general idea is that we are acting based on an incomplete and limited classification system.
The integration or translation of molecular knowledge with our everyday experience is rapidly remodelling the matrix of our way of thinking, and the possible exploitation of the foreseeable classification potentialities could bring radical changes in our behaviour, which might even lead to the redefinition of the role of surgery itself. We thank Francesco Pezzella from Cancer Research UK for his precious and enduring teaching.
*Alfredo Cesario, Domenico Galetta, Patrizia Russo, Stefano Margaritora, Pierluigi Granone *Division of General Thoracic Surgery, Catholic University, Rome, Italy (AC, DG, SM, PG); Molecular Pathology Section, Laboratory of Experimental Oncology, National Institute for Research on Cancer, Genova, Italy (PR) (e-mail: [email protected]) 1
Porter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. London: Harper Collins, 1997.
DEPARTMENT OF ERROR Scheper-Hughes N. Keeping an eye on the global traffic in human organs. Lancet 2003; 361: 1645–48—In this Essay (May 10), the photographs were transposed. Viorel, age 27, Moldova, 2002, is the person shown in figure 2, and kidney broker, Manila, 2002, is the person shown in figure 1. Hardiman P, Pillay OS, Atiomo W. Polycystic ovary syndrome and endometrial carcinoma. Lancet 2003; 361: 1810–12—In this Rapid review (May 24), the second author should have been Ouma C Pillay. Vasudevan AR, Kabinoff GS, Keltz TN, Gitler B. Blunt chest trauma producing acute myocardial infarction in a rugby player. Lancet 2003; 362: 370—In this Case report (Aug 2), the fifth reference should be: Sybrandy KC, Cramer MJ, Bugersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart 2003; 89: 485–89.
THE LANCET • Vol 362 • September 27, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Sir—The Collins dictionary1 defines palliate thus: “to lessen the severity of (pain or disease) without curing [it].” The word is derived from Late Latin palliare (to cover up), from the Latin pallium (a cloak). The Oxford Textbook of Palliative Medicine2 defines palliative care as: “the study and management of patients with active, progressive, faradvanced disease for whom the prognosis is limited and the focus of care is on the quality of life”. Chemotherapy can provide palliative benefit, whether the aim of such treatment is cure, prolongation of life, or simply to gain symptom relief. That is, chemotherapy can help to manage troublesome symptoms and can assist in improving quality of life. In patients with advanced or metastatic cancer, chemotherapy can also provide an important survival benefit, as is the case in many diseases—eg, metastatic breast or colorectal cancer. The potential to extend life is a powerful motivation to accept chemotherapy. Results of many studies3,4 suggest that patients with advanced cancer are willing to endure great toxicity for even a small chance of extended survival although patients and clinicians often have quite different views about the potential benefit that might make treatment worthwhile.3 As a guiding principle, treatment goals should always be clearly understood, to ensure appropriately informed decisions.4 An individual patient might choose to have chemotherapy that could extend their life, but choose not to have treatment if the sole aim was to palliate symptomatic disease. It is therefore important to clearly distinguish these scenarios. Unfortunately, the term palliative chemotherapy has been used to decribe both goals. Indeed even reports from meta-analyses5 that have shown chemotherapy to improve survival have described the treatment as palliative. This description confuses the goals of chemotherapy for both patients and for clinicians. We contend that treatments that could extend life should be described as such. Treatments that aim solely to relieve pain might reasonably be described as palliative. Thus, the term palliative chemotherapy should not be used to describe a treatment regimen, the principal objective of which is to prolong survival. *Michael Jefford, John Zalcberg Peter MacCallum Cancer Centre, Melbourne, Victoria 8006, Australia (e-mail: [email protected])
1082
1 2
3
4
5
Anon. Collins essential English dictionary. Glasgow: Harper Collins, 2003. Doyle D, Hanke G, MacDonald N. Oxford textbook of palliative medicine, 2nd edn. New York: Oxford University Press, 1999. Duric V, Stokker M. Patients’ preferences for adjuvant chemotherapy in early breast cancer: a review of what makes it worthwile. Lancet Oncol 2001; 2: 691–97. Haines IE, Zalcberg J, Buchanan JD. Notfor-resuscitation orders in cancer patients— principles of decision-making. Med J Aust 1990; 153: 225–29. Colorectal Meta-analysis Collaboration. Palliative chemotherapy for advanced or metastatic colorectal cancer (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Wellcome Library, London
Palliative chemotherapy: a clinical oxymoron
The role of the surgeon in translational research William B Coley
Sir—In the late 1890s William B Coley (figure), a young surgeon working in New York, noted that the cancers of some of his patients—who routinely died of post-operative infections—had gone into remission after an episode of erysipelas, a streptococcal infectious disease of the skin. In view of this observation he made the development of vaccines against cancer his life’s work. Commenting on Coley’s experiences, one of his colleagues, a radiation oncologist named James Ewing, asserted that since he was a surgeon and not a scientist, his occasional miracle cures were “probably all baloney”.1 Translational research can be defined as, and implies, a bidirectional process (from biology to relevant interventions) and is usually realised by creating a connection between basic and clinical research. Multidisciplinary teams are involved in translational research, and each person’s effort is based on individual skills. The role of surgeons in these teams is marginal, but the impressive step forward in the biological characterisation of cancer as a result of the sequencing of the genome has brought into surgery a multitude of variables with staggering classification potentialities. In lung cancer, surgery is the only method of cure, but seldom is its application with radical intent possible. Surgical behaviour is based on grossly macroscopic evidence, and the tumour node metastasis system determines almost every surgical indication. Despite the efforts aimed at integrating all therapeutic strategies, the overall outcome of the management of the disease remains disappointing and the general idea is that we are acting based on an incomplete and limited classification system.
The integration or translation of molecular knowledge with our everyday experience is rapidly remodelling the matrix of our way of thinking, and the possible exploitation of the foreseeable classification potentialities could bring radical changes in our behaviour, which might even lead to the redefinition of the role of surgery itself. We thank Francesco Pezzella from Cancer Research UK for his precious and enduring teaching.
*Alfredo Cesario, Domenico Galetta, Patrizia Russo, Stefano Margaritora, Pierluigi Granone *Division of General Thoracic Surgery, Catholic University, Rome, Italy (AC, DG, SM, PG); Molecular Pathology Section, Laboratory of Experimental Oncology, National Institute for Research on Cancer, Genova, Italy (PR) (e-mail: [email protected]) 1
Porter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. London: Harper Collins, 1997.
DEPARTMENT OF ERROR Scheper-Hughes N. Keeping an eye on the global traffic in human organs. Lancet 2003; 361: 1645–48—In this Essay (May 10), the photographs were transposed. Viorel, age 27, Moldova, 2002, is the person shown in figure 2, and kidney broker, Manila, 2002, is the person shown in figure 1. Hardiman P, Pillay OS, Atiomo W. Polycystic ovary syndrome and endometrial carcinoma. Lancet 2003; 361: 1810–12—In this Rapid review (May 24), the second author should have been Ouma C Pillay. Vasudevan AR, Kabinoff GS, Keltz TN, Gitler B. Blunt chest trauma producing acute myocardial infarction in a rugby player. Lancet 2003; 362: 370—In this Case report (Aug 2), the fifth reference should be: Sybrandy KC, Cramer MJ, Bugersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart 2003; 89: 485–89.
THE LANCET • Vol 362 • September 27, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.