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Philosophy of Cancer Care
Philosophy of Cancer Care EDWARD J. BEATTIE, JR.,
M.D.~'
In the United States each year, approximately 3000 new cancers occur per million people. This totals almost 600,000 new cancers per year. It is estimated that approximately one third of the patients with potentially killing cancers are treated successfully; two thirds succumb from their disease. It is further estimated that with optimum care, by present day standards, half of the cancer patients might be salvaged, which would be a net gain per year of about 100,000 patients cured. This high incidence of cancer means that one of six persons will develop a cancer during his lifetime. Indeed, cancer is one of the major health problems of our country. Only 84 years ago, patients with cancer were not admitted to general hospitals. Memorial Hospital for Cancer and Allied Diseases was founded in New York City in 1884 to care for unfortunate persons with cancer, who were considered outcasts from society, suffering from an unmentionable social disease. This reluctance to call cancer by its correct name persists today. There are many medical conditions more promptly fatal than cancer, but we as physicians are often extorted by relatives "not to tell him he has cancer." We agree that no one wants to know the grim, harsh facts of a relatively hopeless future. But trying to care for a patient who cannot understand why he is not promptly getting better from his disease, which is "positively not cancer," is a trying situation for the physician and the relatives alike. A factual, optimistic, and aggressive attitude by the physician is often the best cancer medicine. Besides, cancer is so protean and so often unpredictable that this approach is usually the most reasonable and the most accurate. Over a century ago, the development of anesthesia, followed by the knowledge of antisepsis and asepsis, permitted the development of comfortable and relatively safe surgical operations. Surgeons throughout the world developed operations which began to cure certain types of cancer with reasonable success, such as breast cancer and colon-rectal cancer. Surgery has continued to be the best over-all method of treating cancer successfully. But it was soon recognized that cancers when first From the Department of Surgery ''Chairman, and Chief Medical Officer
Surgical Clinics of North America- Vol. 49, No.2, April, 1969
213
214
EDWARD J. BEATTIE, JR.
seen were relatively far advanced and that too few patients were amenable to an attempt at surgical care. As it became increasingly obvious that surgery was successful only in the minority of the patients presenting themselves with cancer, other kinds of treatment were sought. The discovery of radium and the development of ionizing radiation in the form of x-rays offered the second modality. Early attempts at radiotherapy were with relatively low energy and were found to be successful only when the lesion was superficial, such as in the skin, the cervix, and the oral cavity. Of importance, it was a method of treating cancer that had spread beyond the limits of surgical resection. It became apparent that radiotherapy, too, was controlling only a minority of the cancer problems. The era was soon characterized by disagreement and debate between proponents of surgery and of radiation therapy. A new group of patients developed, and a considerable number of these were ultimately admitted to Memorial Hospital; these were patients in whom radiation therapy had failed, but who still had lesions potentially amenable to surgical excision. Gradually, cooperation between surgeons and radiotherapists developed. The cancer patient came to be treated by a combination of surgery and radiotherapy, with radiotherapy used either preoperatively or postoperatively. With the passage of time it became apparent that early cancers of the cervix and of the vocal cords could be relatively well controlled by radiation therapy, and that some cancers in these areas not controlled by radiotherapy could still be controlled with wide surgical excision. Surgery was not standing still. The development of better anesthesia techniques, blood transfusions and blood banks, intravenous fluids, and antibiotics (which came in the late 1930's and early 1940's) set the stage for extended surgery. There have been attempts to extend surgery to ever greater limits. One problem is to leave the patient with a satisfactory appearance, so that he will be presentable to society. The other problem is to restore function, so that the patient has a satisfactory quality of life and is not just "alive." Some advances have been made. Good orthopedic rehabilitation has made the loss of an extremity much less a catastrophe than heretofore. The use of colon or stomach to reconstruct the esophagus has made it possible for patients to swallow again who otherwise were doomed never to do so. The development of plastic surgical techniques has made more presentable many patients who by necessity have had to be subjected to extensive face, head, or neck surgery. Here the ravages of surgery are difficult to hide, compared to surgery done below the neck or inside the body. Extended radical surgery would be much more possible if organ transplantation were successful. The deterrent still is tissue rejection. Present medical means of controlling rejection are both immunosuppressive and carcinogenic, and thus need much extended study. A new development after World War II was chemotherapy. This modality offered the first opportunity for the intemist to treat cancer medically, at first for palliation and then with the hope of cure. The
PHILOSOPHY OF CANCER CARE
215
search for the "magic bullet" was diligently pursued. For the most part chemotherapeutic agents had remarkable effectiveness in some (and even many) instances, but did not have satisfactory prolonged effects. But in the past two decades encouraging progress has been made. Burkitt's lymphoma, which is a "cancer" of the head and neck region in African children apparently caused by a virus, can be satisfactorily cured by effective use of chemotherapy, and it was discovered that the metastatic chorionepithelioma in the female, hopeless if treated by surgery or radiotherapy, could be cured by the use of chemotherapy. Lymphomas and leukemias, which had been promptly fatal, came under short-range control with some encouraging results. Recently, the first nontoxic chemotherapeutic agent, L-asparaginase, was developed and is presently under study. L-Asparaginase seems to have beneficial effects in two thirds of the acute lymphoblastic leukemias of childhood. The fourth cancer "treatment," namely epidemiology and preventive medicine, has only recently been pursued. Knowledge that cancer could be an occupational disease stems from the descriptions of scrotal cancers of chimney sweeps in England, written by Sir Percival Pott in 1775. There have since been observations on the hazards of cancerogenesis from arsenic, radium, and coal tars. Much remains to be studied. There is wide discrepancy around the world in the incidence of cancer by organ systems. Japanese have a high incidence of cancer in the esophagus and stomach, but a low incidence in the colon and breast. Americans have a low incidence in the esophagus, but a high incidence in the breast and colon. The high and rising rate of lung cancer in the American male who smokes is a well-known fact. The difficulty in getting people to stop smoking cigarettes is too obvious for commentary. The discovery by Papanicolaou that tumor cells can be found by cytologic examination gave an effective tool for earlier diagnosis and mass control of cancer. The greatest success has been in cancer of the cervix, where a routine Papanicolaou smear biannually from age 20 on should ultimately prevent women from dying of cervical cancer. Unfortunately, this knowledge is not universally applied, and there are many women dying unnecessarily from cancer of the cervix. It is possible by the use of chest x-rays and sputum cytology twice yearly to diagnose a certain number of lung cancers at an early stage. In a small series of such patients at Memorial Hospital, it has been found that if the tumor can be found and localized by split cytologic studies at the time of bronchoscopy, by tomograms, bronchograms, or angiograms, the curability of lung cancer at this stage is approximately 65 per cent, in comparison to 40 per cent in "coin lesions" and a much lower percentage for more advanced cancers of the lung. The modality for potential cancer treatment that presently needs exploration is immunotherapy. The real question is not that one person out of six develops cancer, but why five out of six never do. In experimental animals, there is evidence that cancers induced by chemical agents can produce antibody lymphocytes if injected into another animal. These antibodies can then suppress the growth of cancer if injected back into the original animal with the tumor. This mechanism needs greater
216
EDWARD ]. BEATTIE,
]R.
study, and the role of tumor antigens and tumor antibodies in man needs clarification. The possibility remains that cancer in man is virus induced, although except for the Burkitt's "lymphoma" virus, there has not yet been a virus recovered from human cancer. It is apparent that the care of the cancer patient at present is a manypronged, conjoint attack. Each patient needs careful study and evaluation. Every attempt should be made to control the disease and prolong life as long as the patient is comfortable and the quality of life is satisfactory. Heroic attempts to maintain life in the suffering, hopeless situation seem ill-advised. But great care must be taken that a situation be considered hopeless only when it is truly hopeless. It is obvious that the operability and resectability of a tumor will depend to a very great extent on the surgeon's skill and experience with that type of surgery, and that generalizations cannot be made which could be applied uniformly over a country as large as the United States. Palliative surgery, which is done to make the patient more comfortable or to live more comfortably for whatever time he has to live, is justified in carefully selected patients. It is wise that there be close cooperation in any given hospital among the surgeons, physicians, and radiotherapists interested in the cancer problem, so that they can render good advice, support, and help to each other. In no other field of medicine is it more important than that there be a close physician-patient and patient-family relation. Follow-up of the cancer patient is equally important, though too frequently neglected by the medical profession. It is obvious that the patients who are not cured of cancer should be followed frequently, if for no other than humane reasons. Patients potentially cured need close observation. It is possible that local recurrences will occur or problems will arise which are still amenable to correction if found and treated early. It is also true that a rather high percentage of cured patients will develop new cancers. In studies at Memorial Hospital we have found that the cancer patient who is thought to be cured of cancer develops important new problems at the rate of approximately 7 per cent per year. This means that careful scrutiny in following the cancer patient for life is a mandatory part of cancer care. One must never fall into the trap of assuming that new cancers are metastases from unsatisfactorily treated former cancers.
M.D.~'
In the United States each year, approximately 3000 new cancers occur per million people. This totals almost 600,000 new cancers per year. It is estimated that approximately one third of the patients with potentially killing cancers are treated successfully; two thirds succumb from their disease. It is further estimated that with optimum care, by present day standards, half of the cancer patients might be salvaged, which would be a net gain per year of about 100,000 patients cured. This high incidence of cancer means that one of six persons will develop a cancer during his lifetime. Indeed, cancer is one of the major health problems of our country. Only 84 years ago, patients with cancer were not admitted to general hospitals. Memorial Hospital for Cancer and Allied Diseases was founded in New York City in 1884 to care for unfortunate persons with cancer, who were considered outcasts from society, suffering from an unmentionable social disease. This reluctance to call cancer by its correct name persists today. There are many medical conditions more promptly fatal than cancer, but we as physicians are often extorted by relatives "not to tell him he has cancer." We agree that no one wants to know the grim, harsh facts of a relatively hopeless future. But trying to care for a patient who cannot understand why he is not promptly getting better from his disease, which is "positively not cancer," is a trying situation for the physician and the relatives alike. A factual, optimistic, and aggressive attitude by the physician is often the best cancer medicine. Besides, cancer is so protean and so often unpredictable that this approach is usually the most reasonable and the most accurate. Over a century ago, the development of anesthesia, followed by the knowledge of antisepsis and asepsis, permitted the development of comfortable and relatively safe surgical operations. Surgeons throughout the world developed operations which began to cure certain types of cancer with reasonable success, such as breast cancer and colon-rectal cancer. Surgery has continued to be the best over-all method of treating cancer successfully. But it was soon recognized that cancers when first From the Department of Surgery ''Chairman, and Chief Medical Officer
Surgical Clinics of North America- Vol. 49, No.2, April, 1969
213
214
EDWARD J. BEATTIE, JR.
seen were relatively far advanced and that too few patients were amenable to an attempt at surgical care. As it became increasingly obvious that surgery was successful only in the minority of the patients presenting themselves with cancer, other kinds of treatment were sought. The discovery of radium and the development of ionizing radiation in the form of x-rays offered the second modality. Early attempts at radiotherapy were with relatively low energy and were found to be successful only when the lesion was superficial, such as in the skin, the cervix, and the oral cavity. Of importance, it was a method of treating cancer that had spread beyond the limits of surgical resection. It became apparent that radiotherapy, too, was controlling only a minority of the cancer problems. The era was soon characterized by disagreement and debate between proponents of surgery and of radiation therapy. A new group of patients developed, and a considerable number of these were ultimately admitted to Memorial Hospital; these were patients in whom radiation therapy had failed, but who still had lesions potentially amenable to surgical excision. Gradually, cooperation between surgeons and radiotherapists developed. The cancer patient came to be treated by a combination of surgery and radiotherapy, with radiotherapy used either preoperatively or postoperatively. With the passage of time it became apparent that early cancers of the cervix and of the vocal cords could be relatively well controlled by radiation therapy, and that some cancers in these areas not controlled by radiotherapy could still be controlled with wide surgical excision. Surgery was not standing still. The development of better anesthesia techniques, blood transfusions and blood banks, intravenous fluids, and antibiotics (which came in the late 1930's and early 1940's) set the stage for extended surgery. There have been attempts to extend surgery to ever greater limits. One problem is to leave the patient with a satisfactory appearance, so that he will be presentable to society. The other problem is to restore function, so that the patient has a satisfactory quality of life and is not just "alive." Some advances have been made. Good orthopedic rehabilitation has made the loss of an extremity much less a catastrophe than heretofore. The use of colon or stomach to reconstruct the esophagus has made it possible for patients to swallow again who otherwise were doomed never to do so. The development of plastic surgical techniques has made more presentable many patients who by necessity have had to be subjected to extensive face, head, or neck surgery. Here the ravages of surgery are difficult to hide, compared to surgery done below the neck or inside the body. Extended radical surgery would be much more possible if organ transplantation were successful. The deterrent still is tissue rejection. Present medical means of controlling rejection are both immunosuppressive and carcinogenic, and thus need much extended study. A new development after World War II was chemotherapy. This modality offered the first opportunity for the intemist to treat cancer medically, at first for palliation and then with the hope of cure. The
PHILOSOPHY OF CANCER CARE
215
search for the "magic bullet" was diligently pursued. For the most part chemotherapeutic agents had remarkable effectiveness in some (and even many) instances, but did not have satisfactory prolonged effects. But in the past two decades encouraging progress has been made. Burkitt's lymphoma, which is a "cancer" of the head and neck region in African children apparently caused by a virus, can be satisfactorily cured by effective use of chemotherapy, and it was discovered that the metastatic chorionepithelioma in the female, hopeless if treated by surgery or radiotherapy, could be cured by the use of chemotherapy. Lymphomas and leukemias, which had been promptly fatal, came under short-range control with some encouraging results. Recently, the first nontoxic chemotherapeutic agent, L-asparaginase, was developed and is presently under study. L-Asparaginase seems to have beneficial effects in two thirds of the acute lymphoblastic leukemias of childhood. The fourth cancer "treatment," namely epidemiology and preventive medicine, has only recently been pursued. Knowledge that cancer could be an occupational disease stems from the descriptions of scrotal cancers of chimney sweeps in England, written by Sir Percival Pott in 1775. There have since been observations on the hazards of cancerogenesis from arsenic, radium, and coal tars. Much remains to be studied. There is wide discrepancy around the world in the incidence of cancer by organ systems. Japanese have a high incidence of cancer in the esophagus and stomach, but a low incidence in the colon and breast. Americans have a low incidence in the esophagus, but a high incidence in the breast and colon. The high and rising rate of lung cancer in the American male who smokes is a well-known fact. The difficulty in getting people to stop smoking cigarettes is too obvious for commentary. The discovery by Papanicolaou that tumor cells can be found by cytologic examination gave an effective tool for earlier diagnosis and mass control of cancer. The greatest success has been in cancer of the cervix, where a routine Papanicolaou smear biannually from age 20 on should ultimately prevent women from dying of cervical cancer. Unfortunately, this knowledge is not universally applied, and there are many women dying unnecessarily from cancer of the cervix. It is possible by the use of chest x-rays and sputum cytology twice yearly to diagnose a certain number of lung cancers at an early stage. In a small series of such patients at Memorial Hospital, it has been found that if the tumor can be found and localized by split cytologic studies at the time of bronchoscopy, by tomograms, bronchograms, or angiograms, the curability of lung cancer at this stage is approximately 65 per cent, in comparison to 40 per cent in "coin lesions" and a much lower percentage for more advanced cancers of the lung. The modality for potential cancer treatment that presently needs exploration is immunotherapy. The real question is not that one person out of six develops cancer, but why five out of six never do. In experimental animals, there is evidence that cancers induced by chemical agents can produce antibody lymphocytes if injected into another animal. These antibodies can then suppress the growth of cancer if injected back into the original animal with the tumor. This mechanism needs greater
216
EDWARD ]. BEATTIE,
]R.
study, and the role of tumor antigens and tumor antibodies in man needs clarification. The possibility remains that cancer in man is virus induced, although except for the Burkitt's "lymphoma" virus, there has not yet been a virus recovered from human cancer. It is apparent that the care of the cancer patient at present is a manypronged, conjoint attack. Each patient needs careful study and evaluation. Every attempt should be made to control the disease and prolong life as long as the patient is comfortable and the quality of life is satisfactory. Heroic attempts to maintain life in the suffering, hopeless situation seem ill-advised. But great care must be taken that a situation be considered hopeless only when it is truly hopeless. It is obvious that the operability and resectability of a tumor will depend to a very great extent on the surgeon's skill and experience with that type of surgery, and that generalizations cannot be made which could be applied uniformly over a country as large as the United States. Palliative surgery, which is done to make the patient more comfortable or to live more comfortably for whatever time he has to live, is justified in carefully selected patients. It is wise that there be close cooperation in any given hospital among the surgeons, physicians, and radiotherapists interested in the cancer problem, so that they can render good advice, support, and help to each other. In no other field of medicine is it more important than that there be a close physician-patient and patient-family relation. Follow-up of the cancer patient is equally important, though too frequently neglected by the medical profession. It is obvious that the patients who are not cured of cancer should be followed frequently, if for no other than humane reasons. Patients potentially cured need close observation. It is possible that local recurrences will occur or problems will arise which are still amenable to correction if found and treated early. It is also true that a rather high percentage of cured patients will develop new cancers. In studies at Memorial Hospital we have found that the cancer patient who is thought to be cured of cancer develops important new problems at the rate of approximately 7 per cent per year. This means that careful scrutiny in following the cancer patient for life is a mandatory part of cancer care. One must never fall into the trap of assuming that new cancers are metastases from unsatisfactorily treated former cancers.