THE OTHER FACE OF CANCER

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CANCER AS A HUMAN PROBLEM

Cancer, Timothy Foote 34 wrote, is a mysterious plague that cries out not for philosophy, but for a palliative. The cataloguing of the biological features of cancer in the earlier chapter cannot ameliorate the hurt feelings and the dis-eased body of a cancer patient. Cancer is a human problem, as are other diseases, and death. Haldane, 35 the noted geneticist, who died of a rectal cancer conceded that 'cancer often kills,' only to add with a chuckle, that 'so do cars and sleeping pills.'

What biological understanding can do for a cancer patient, his near ones and even his doctors, is to help them to see and tackle the issue without fear, incrimination, rushing for needless therapies, or the typi- cal 'j'accuse' from the doctor to the patient because he 'came too late.' Cancer, so often, does not mean a death-sentence, and is com- patible with a long life. Freud, the father of modern psychiatry, devel- oped cancer of the mouth at the age of 67, and died of something different altogether, at the age of 83. 36 It is not for us too choose the whether, what and when of cancer. Rather when cancer does occur, we must make the best of it.

As paradigms of human cancer, let us construct a model of the dis- ease, interspersed with pertinent biologic data, in (a) any one of the three cancer surgeons, Mayo, Wilkie and Borges (Chapter 1), who died of cancer of the stomach; (b) Aldous Huxley, who fell victim to a cancer of the tongue, 37 (c) Lenore Schwartz, a young Chicago scholar, artist and teacher who died of leukemia at the age of 23, and in whose name the Lenore Schwartz Leukemia Research Foundation at Florida was established, 38 and (d) John Gunther, Jr., who died of a brain can- cer while still in his teens. 39

The inception of the cancer, in each person listed above, was as a very small, silent event that predeterminedly affected, at one or more places, a small number of cells - cells that were originally normal. The newly formed cancerous cells started multiplying, but no faster than normal cells as was hitherto thought. This slowness of cancer cells' proliferation, in comparison with the rate of proliferation of normal cells, confirmed over a wide range of cancers, 6,40,98,258,315 has led to the sug- gestion 40 that cancer be better regarded as a disease of cell-accumu- lation rather than of rapid proliferation.

A cancer cell measures no larger than a normal cell - one- hun- dredth of a millimeter across. This sheer micro-size of a cancer cell accounts for the fact that, following the inception of cancer, it must have ordinarily taken several years before the cancer bothered these individuals, or came to the attention of their doctors. On the basis of the modern cytokinetic studies, it has been computed that any can- cer, before causing symptoms or striking the eyes of the clinician, takes anything from two to seventeen years - two and a half years for a rapidly fatal cancer as of the lung to seventeen years for breast cancer. And during this interval, there is no instrumental, immuno- logical, or biochemical method that could detect this microscopic focus of growing cancer, be it the amazingly sophisticated tomogra- phy, 308 or the quantitative imaging 311 designed to synchronously scan up to 250 parallel transverse cross-sections of the human body. A cancer just one cubic mm in size is worth at least 1,000,000 cells. 41 Any diagnosable cancer is thus, at least a-million-cell-worth, and many years old, with twenty-four hours of each day of each year at its disposal to leave the starting point and go and lodge elsewhere in the blissfully unaware individual. 42

Let us be happy that the six luminaries of our story were not deprived of the much-sought-and-advertised 'early-diagnosis' for want of the latest computer off the IBM assembly line. As far back as in 1927, Cheatle, 43 writing in the British Medical Journal declared that 'when a lump appears in the carcinoma, the disease is well advanced, and is already threatening the patient's life, possibly beyond all hopes of cure.' What Cheatle said of breast cancer in 1927, Logan 12 repeated in 1975, with the question - is there anything like an early cancer?

In Mayo, Wilkie and Huxley, the discovery of the tumour was sudden, and until that time they neither had the knowledge of it, nor any prob- lems. They were operated, unrewardingly. Borges, a humanitarian as we knew him, was feeling uneasy for some time, but he took it as gastric upset and continued to work; then, one day, he was investi- gated and operated upon. Borges lived and worked for many months after that until the spread caused obstructive jaundice to which he succumbed, with dignity. A few months before his death, he delivered an oration at Pune ( Maharashtra State), India, and a part of the ora- tion is reproduced here, courtesy of Lr. Dr. Bhagwat, lately of the Armed Forces Medical College, Pune: 'I have treated thousands of cases surgically, radiologically and by cytotoxic drugs. A number of times people met me later and said, "Doctor, if I knew I was going to live like this, I would not have come to you." I have rarely failed to diagnose a case when the disease was not quite controllable! I have left the dis- ease and removed the patient in many cases. I have succeeded in leaving behind a trail of family-malnutrition and many of their children without education. I have now come to the conclusion that, let us in every case ask whether it is not wiser to leave the patient to be re- leased by death than to try to relieve him by surgery; cure is only a dream yet!'

What Borges emphasized, on the eve of his long career as a cancer- ologist, was the cacotelic nature of cancer therapy. ( Cacotelic , from Greek, means tending to end badly ). Gius 259,260 introduced this term to drive home an important cancerologic lesson: 'Operations intended to palliate (or even cure) may sometimes make the patient worse than he was initially.' The modern cancerologists ought to take a cue from the foregoing, and be publicly candid about cancer therapy. But they won't. As one senior scientist of the National Cancer Institute con- fessed: 'It just doesn't pay to rock the boat.' 44

The course of Ms. Schwartz's illness is not available to the authors, but a fair guess can be made. The possibility that for quite some time she must have been blissfully free of any symptoms may be realized from the recently established fact that in leukemia, when there is com- plete remission a patient's bone marrow has at least a 1000 million cells. 45,265 At some stage then her leukemia could have returned from the silent to the clinical stage. She could have had fever or a sore throat, or felt weak or out-of-sorts; then came the blood counts and the frightening diagnosis of leukemia was established.

What treatment must she have received? X-ray therapy and/ or che- motherapy, both greater enemies to many a normal cell from head-to- foot, bowel to bone marrow. Lenore's leukemic count must have gone down, to the academic satisfaction of her doctors, but so must have her vitality, resistance and hemoglobin. Eventually, Lenore succumbed, we do not know to what - the disease or the treatment ! Many a leuke- mia gets controlled, but the patient dies. Perhaps, it may be argued, had she lived, or had had her leukemia now, her bone marrow, the seat of the leukemic process, could have been first destroyed com- pletely by very heavy doses of toxic drugs and X-rays, rendering it thus free of any cells, cancerous or normal. The now-completely-de- fenseless patient could have been grafted with bone marrow from another human to give the patient white / red cells indispensable for survival, as also hopefully to give donor-lymphocytes that would act against any residual leukemia. But such superheroic measures have proved tragically futile: twenty-four leukemic cases were grafted. 46 In seven cases, the graft failed to survive and the patients died with 'aplasia' or completely cell-less bone marrow. In seventeen, the graft succeeded only to unleash a vicious attack on the host - ' "the graft-versus-host disease (GVHD)" which is particularly severe in man' 46 - to kill thirteen patients, ten in no time, two after some time, and one a little later. The remaining four with successful graft died with 'controlled; GVHD and recurrent leukemia. The foregoing prob- lems reported 46 in 1969 remain essentially unchanged today. 272-275

The saga 39 of John Gunther Jr. is too well-known to be described here. The brave boy was treated with the most advanced allopathic and the most hopeful naturopathic measures, but to no avail. The fault wasn't with the treatment but with the cancer. All brain cancers, even when they appear 'benign' to the microscopists have, what Willis 20 calls, a 'wide field of origin.' You remove it at one place, and the next one grows for recognition, and may be removed. In the end, the can- cer wins, for want of sacrificeable brain.

The true-to-life stories above may appear grim and selective. One could as well have picked up eminent people who did very well - pa- thologist-author Boyd, Alexander Solzhenitsyn, Sigmund Freud, John Wayne. But the essential sequence of events remains the same, whether the cancer is benign or otherwise. The most important moral, if there may be any, of the above accounts is that cancer is mercifully quiet and unobtrusive for many years after its inception. And there lies the benignancy of this malignant process.

There are some more human issues confounded by the seeming vagaries of cancer. 'Why, me when I never smoked and why not my friend who always did?' Cancer affects more-or-less a fixed percent- age of the herd, and it all depends where one gets caught in this probability distribution. Of those who get it, the age at which cancer occurs is normally distributed so that the one gets it at 19, the other at 39 and the third at 93. Such distribution holds true both for overall cancer and for cancer at one particular site.

Some cancers allow a longer lease of life, with no treatment or mini- mal treatment while others, of the same histological variety, prove rapidly fatal despite timely and adequate treatment. The secret of this lies in the cancer itself, the survival-time itself being normally distrib- uted, thus accounting for the early death of Karnofsky the cancer- specialist, and a long active life for John Wayne, the Hollywood hero, both having had cancer of the lung. Such unpredictable autonomy of cancers has led cancerologists to classify, albeit a posteriori, cancers as good, and bad, the former amenable to any treatment, the latter to none. 3 In a larger perspective, the goodness or badness resides not so much even in cancer itself, as much as in the helplessly unpredict- able nature of any individual's biological trajectory.

What Makes Cancer Incurable?

The real enemy of cancer cure is not the cancer itself, but the adja- cent normal cell, waiting for its turn to grow cancerous.

In cancerologic parlance, this process of normal cell joining the cancerous troop is called recruitment . The cancerous army thus can potentially become as big as that of the normal cells in the body. This simple fact rules out the cancerologist's dream of 'The Last Surviving Cancer Cell: The Chances of Killing it.' 47 That is not all. While surgery's fault lies in spreading 246,247 a cancer which was localized, X-ray therapy 6,248.249 and chemotherapy 6,8,15,101,102,250 are agencies recognized for their ability to induce normal cells to cancerate faster: 'The carci- nogenic activity of many of our chemotherapeutic agents is now un- der advisement.' 250 Chemotherapy can render 251 berserk a benignantly behaving malignancy and be effective to the point of being lethal: 'The aggressive chemotherapeutic approach used ... is often lethal to the patient with LRE (Leukemic Reticolo-Endotheliosis, a type of leu- kemia).' 252

The only human cancer that does not present this Damoclean de- meanor of recruitment is the rare gestational choriocarcinoma that occurs in women following pregnancy. But this is so, because it is a cancer 'transferred' 20 from the fetus to the mother, thus not being au- tochthonous, or springing from the mother's own tissues. Naturally such a cancer allows a complete cure, for after 'the last cancer cell,' there are no normal cells to recruit. This is, as yet, the solitary triumph of cancer chemotherapy, for reasons that reside exclusively in the cancer.

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