THE OTHER FACE OF CANCER

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NOT CURABLE, HIGHLY PALLIATABLE

T he raison d'etre of cancer therapy is that the chief clinical mani- festation of cancer is a mass of cells - a celluloma called a tumour or a lump. A cancer therapist's knowledge begins with a tumour, and

ends with it. By a variety of measures, the tumour or the lump can be made to disappear. The whole cycle of detection and destruction of the lump is repeated on the reappearance of the lump. It is a sobering thought that cancer therapy is nothing more than glorified 'Lumpology'.

Tumour and Before

As elaborated earlier, both the patient and the doctor are blissfully unaware of all the happenings, till such time as the tumour dis-eases the owner or is detected by the doctor. It is all ignorance from the start of cancer up to the time of detection of the tumour.

Tumour and After

What, once the tumour is found and removed? Back to ignorance again for some inescapable reasons: The incurable individuality of each cancer and of its owner make unpredictable, (a) what the can- cer will now do to the patient, and (b) what the treatment will do to the cancer. Regarding the former, the course may be, like for the celebri- ties listed in chapter three, inexorably downhill, despite all possible measures. Or, as for the pathologist-author Boyd 51 the tumour may not reappear for a lifetime.

Treatment, in fact, may aggravate the cancer: Even after considering the most painstaking criteria of operability, there are women in whom surgery manages to accelerate the evolution of breast cancer. 82 Surgical intervention may markedly precipitate distant spread, so that 'surgical intervention must be excluded as the first therapeutic step, even in stage I breast cancer.' 83 Surgery, the oldest, most widely employed, and relatively the most innocuous of all measures, is itself beset with such unpredictable hazards. What then could one say of radiotherapy and chemotherapy with their indiscriminate cytotoxic and 'marrow devastating' 84 potential?

Treated, the tumour is out, the cancer is not , much less the cancerability of normal tissues. Over a century ago, Billroth 85 aphorized that sur- gery removes a tumour, but not the patient's diathesis for cancer. 'Un- fortunately it must be admitted that all cancer surgery is in large mea- sure palliative, given the occult spread of disease before treatment in a high percentage of cases.' 86 The much celebrated victory over leu- kemia must content with the fact that, although by definition the pe- ripheral blood picture and the bone marrow are normal during com- plete remission, 100 million to 1000 million leukemic cells still remain, making relapse inevitable. 45

Whither Cancer Treatment?

Thus, all told, prior to the detection of and after the detection/treat- ment of a tumour, clinicians are still almost know-nothings.

Glemser's world-wide survey of Man Against Cancer 22 only revealed that the realistic title of his book could have been Man Helpless Against Cancer: Surgery was declared dispensable, radio-therapy obsolete, and chemotherapy an absolute farce. As of 1969, 22 any talk of treat- ing cancer was tantamount to Ecclesiastes' Vanitas vanitatum: 'Noth- ing is worth doing, no way is better than another.' 87 Has real progress been made?

'At the present time', Brooke 88 generalized in 1971, 'cancer treatment appears to have reached a culmination, a peak beyond which we have not moved for several decades.' But as all the therapeutic measures against cancer, as of today, are held dispensable, we are forced to conclude that what cancer therapy reached was its Peterian 150 (cf. Pe- ter Principle) zenith of imperfection 'several decades' ago, and all that we have been doing is to move in circles and call it 'progress,' 'recent advances' and so on. Such euphemisms may be justified on the geo- metric ground that all circular motions are made up of a series of mo- tions in a straight line, and any straight line motion implies progress.

Cancer therapy has almost entirely betrayed the application of lumpolytic logic to the false premise of a cure. Watts 89 has described the peculiar and perhaps fatal fallacy of modern times: the confusion of symbol with reality. Such fallacy dominates cancerology so that what is diagnosed and treated is not cancer - 'a disease of the whole organism' 17 - but merely its most evident manifestation, a lump or an -o ma. The consoling cures obtained are 'largely limited to some unusual forms of malignant disease, such as chorionic epithelioma (gestational choriocarcinoma) in women,' 90 being a function of the nature of the cancer, rather than due to any ingenuity of the hit-and- miss treatment.

And Yet Cancer Must be Treated

However, the indispensable role of cancer therapy must be empha- sized. Despite the accepted impotence of all therapies against au- tochthonous cancer, one and all measures are useful when employed to ease a dis-eased cancer patient. A cancer patient with a blocked gullet or intestinal obstruction, a mass in the brain, a massive un- gainly jaw from Burkitt's tumour, a fungating mass in the breast, or a large sarcoma of the bone cannot be subjected to a course on the philosophy of whither cancer therapy, but must be eased immediately with an appropriate palliative measure. Cancer will be with mankind forever, being a part, and progenitor of it. Cancer therapists will be needed to play their vital palliative role as long as mankind survives.

With this background, we can now draw some generalizations on cancer therapy.

1. Cancer, a process characterized by accumulation of newly formed cells, dis-eases an individual when it forms a mass or a tumour large enough to obtrude on the physiology or the psyche of the patient. Equally, it comes to the stage of diagnosability by the doctor, only when it is many million cells strong and quite a few years old. The therapy of cancer, except for the 'gestational choriocarcinoma,' is always a palliative measure.

2. A cancer's manifestation may be (a) restricted locally as a lump in the tongue, esophagus, brain or on the arm, (b) also found regionally as when a tongue cancer spreads to the lymph nodes in the neck, or (c) all over the body - 'systemic disease' - as in blood cancer, lymph node cancers and some cancers such as melanoma that have spread all over.

3. Cancer present as a local and/or regional mass is most ame- nable to being cut a way by surgery, together usually with a fair margin of healthy tissues. Most cancer so present themselves and are so treated. Surgery - conservative, radical or supraradical

- is the sheet-anchor of cancer therapy. The surgical removal of malignant tumours is the oldest form of treatment for this condi- tion, has retained its leading role in the course of centuries and is still the treatment of choice in a high percentage of cases.' 91

4. Systemic or whole-body cancers, such as blood cancers (leuke- mias), Hodgkin's disease, other lymphomas, may be managed by systemic or whole-body measures such as X-ray therapy and cell-poisons euphemistically called anticancer drugs. Cancers starting locally - melanoma, lining of the uterus, intestine - may spread to various sites in the body so that the treatment has to be given as for systemic cancers.

5. Some cancers, as of the breast, thyroid, prostate, respond, albeit unpredictably and temporarily, 15 to administration of hormones and/or ablation of glands secreting hormones.

6. In all leading centres, a combination of therapeutic measures is usually employed. The advantage of surgery is a total absence of toxic action on other cells; its limitation is its limited reach. X-ray therapy and chemotherapy provide an all-body reach; their out- standing limitation is the toll they take of the many cell-popula- tions that divide faster than many a cancer. The common result is

- the hair fall off, the mouth, intestine and skin ulcerate, and the patient becomes pale and defenseless because of the depres- sion of bone marrow.

7. The follow-up insisted upon by cancer therapists is to watch for recurrence of the lump (or the heightened cell count as in leuke- mias). The logical sequence to recurrence is treatment, all over again. Sigmund Freud had thirty-three operations for his oral cancer, over a period of sixteen years. 36

8. The science of cancer therapy does not exclude such measures as analgesics, stronger pain-killers as morphine, transfusions, dietary supplements and so on so as to make the patient feel better.

9. It may be difficult to realise that one of the most fruitful measures in cancer therapy is an attack on the I- worry tower of the patient

- the tower crumbles against the power of a positive approach. 'The victims of this disease,' Weil 92 aphorized as far back as 1915, 'seem to be in a very high degree "suggestible" and impressionable and respond nobly to every therapeutic effort.' Issels' experience seems to bear out Weil's observation: 'In the twenty years of experience with the so-called incurables, I have seen that reservoirs of undreamt-of strength and courage can be drawn upon, even in "terminal" cases by the adoption of positive attitude.' 93 Lewin 94 has talked of a physician needing the ability to manage his own anxiety against cancer; what kills a patient often is the everything-is-lost attitude of his physician which is betrayed in his eyes, words, tone or even in the way he walks towards the patient's bed.

Cure-rates in Cancer Therapy

With average survival not extending beyond three to four years for the majority of cancers treated by the best hands in the best centres, it has become imperative to talk of five, ten year, and twenty year cure rates, albeit at the level of a group of patients similarly treated for a supposedly similar disease. In an age when it is advocated that the patient should be fully apprised of the gravity of his disease, the severity of the treatment and the unpredictability of the outcome, it is as well that the patient is told that his survival is a herd function rang- ing from three months to thirty years, and that his own survival would depend on what place he occupies, through probability distribution, on the herd survival curve.

'When it comes to appraising the effectiveness of treatment,' Sutherland 95 comments, 'one of the difficulties is the striking range in the natural duration of cancer of the same site in a series of cases.' Sutherland 95 gives among many cancers, the natural duration of cancers (left untreated) of the tongue and oral cavity in males ranging from three months to seventy five months, and of the cervix uteri and female breast, from three months to twelve and a half years and two months to seventeen and half years respectively.

The most commonly cited five year survival rate as a standard of cure is comparative and fallacious assuming as it must that all the cases 'if untreated would have a nil per cent five year survival rate.' 67 The real cure rate , Park and Lees 67 define, is represented by the difference be- tween the five year survival rate of all cases following treatment and the five year survival rate of those same cases had they been left untreated. ' In several forms of cancer, survival for five years after a therapeutic procedure means little by itself, since a considerable proportion of un- treated patients are known to survive five years or longer.' 96 Park and Lees, 67 in a detailed, highly critical article entitled, 'The absolute cur- ability of cancer of the breast,' and containing numerous graphs and statistical calculations, concluded that (a) it could not be proved that the survival rate of breast cancer, using as an index the five year sur- vival rate, was in any way affected by treatment, (b) treatment was quite ineffective in reducing the mortality from metastatic spread, and (c) if the treatment was 'in any way' effective, the so-called effective- ness could not exceed that required to increase the overall five year survival rate by more than 5% to 10%.

The whole business of five year, ten year and x-year survival rates is marred by the fallacy of an early or late 'countdown'. 97 Ms. A has a breast lump, and she does not bother about it for four years. Then she decides to get it treated, and dies after two years, to be registered as a case that came late and therefore, died early. Ms. B has a similar lump, she gets treated within six months, lives for four years, and is registered, in contrast to Ms. A, as the case that came earlier and survived longer. In reality, Ms. A lived with her cancer for six years, and Ms.B for four and half years. The apparent longer survival of Ms.B was because the countdown on her started earlier. An extended limi- tation of the above fallacy of the countdown arises from the fact that no one - neither the patient nor the doctor - knows exactly when the cancer started in the body.

A cancer patient, at an individual level, is no statistic, as he is often made out to be. Carrying within himself two forms of uniqueness, one his own and the other that of the cancer he carries, he does not lend himself to any fruitful predictions or comparisons.

Victory over Childhood Leukemia

The current showpiece 14,22,271 of the cancer world is the hard-won victory over an otherwise rapidly fatal leukemia in children, called the acute lymphoblastic leukemia, usually abbreviated as ALL. Firstly, we may see the nature of the success and then understand its mecha- nism.

Nature of Success 45,98,265-277,315

i. Before the introduction of 'effective' therapy, the average survival rate was less than three months: now a small percentage of pa- tients survive five years and more. The continuing survival of an ALL patient, under therapy, with disappearance of leukemia cells from the bone marrow and blood is generally called 'remission,' a term applicable to other forms of leukemia as well.

ii. Leukemia cells persist during remission, for the disease rapidly recurs on discontinuation of therapy: 'It has been estimated that before treatment the cancer patient has about 10 12 (1000 billion) or more malignant cells in his body, and that when he is brought into so-called complete remission he still has from 10 9 (one billion) to 10 10 (10 billion)viable malignant cells.' 265

iii. The observed increases in average survival, therefore, reflect only improved palliation.

iv. The most important factor in survival is not the type of leukemia cells nor their pre-treatment number, but the response to therapy - a factor that unpredictably resides in an individual patient and his cancer, and not in the treatment. Under the same therapy, boys may fare significantly 269 worse than girls.

v. The treatment accorded to ALL cases is no different from that given in other forms of leukemia, or cancers. The treatment comprises agents - drugs, X-rays, - that act as cancer-inducing agents in the laboratory, and sometimes in humans. The compli- cations of the therapy of ALL are as varied and formidable as with other cancers. Despite remission, patients die seemingly not of leukemia, but of infections of the most unusual nature by micro-organisms that are ordinarily non-pathogenic, or of sud- den hemorrhage.

vi. Therapy of ALL produces remission possibly by pushing the disease, as it were, under the carpet. While the therapy is busy providing remission by clearing the bone marrow and blood of leukemia cells, leukemia cells settle in the brain, spinal cord, meninges, testes etc., to eventually bring about the so-called ex- tramedullary (outside the bone marrow) relapse. Certain drugs 268 probably assist such transfer of the disease from the bone mar- row to elsewhere.

vii. ALL therapy is essentially a titration between killing more leuke- mia cells while hoping to kill less of normal cells. 315 No known treatment of ALL has such selective action. 98 Drugs and X-rays exercise relentless toxicity, and the leukemia cells commonly turn resistant to the action of drugs.

viii. Newer methods 271-275,315 of treating ALL are afoot - varied types of immunotherapy, and bone marrow transplantation. The formidable problems posed by transplantation - 'a harrowing method of treatment ' 275 - are nowhere near a solution, and present a highly nocuous double-edge: The transplantee must be pre-prepared to accept the transplant by intensive drugging and irradiation that render the patient thoroughly defenseless against infections. Should the grafting succeed, the guest-marrow-cells show no compunction in letting loose on the host a vicious graft-versus- host-reaction/disease, usually abbreviated as GVHR/GVHD. Transplant means a 'cure rate of perhaps 10%' 275 and 'death for many of the remainder.' 275

ix. The lay 14 and learned 271 exhortations to subject more and more ALL cases to the aggressive cure-or-kill therapy rarely amplify the facts 98 that the treatment is merely palliative, increasingly com- plex, costly in terms of money and therapeutic complications, fraught with uncertainty all the time, an emotional gamble for the patient/relatives/physician, and that regardless of the 'supra- intensive therapy' 274 fatality far exceeds survival.

x. In 1957, Burkitt discovered in African children a cancer, called Burkitt's tumour/lymphoma, and now reported from all parts of the world. 22,266,276 Burkitt's contribution was held as something utterly unique in medical history,' 22 for it pointed to a viral origin of cancer, an assumption that could not 15,276 be proved right. The initially dramatic way in which Burkitt's tumour responded to che- motherapy led to the hope that this may lead to 'the eventual control of Acute Lymphocytic Leukemia (ALL).' 277

A parallel may be profitably drawn at this stage between ALL and Burkitt's tumour: Both are essentially made up of 'lympho- blasts,' 98,276 occur predominantly in children, respond rather dramatically to drugs combined with X-ray therapy, and what is most important, both were and are held as leads towards finding the cause and cure of cancer. Points (I) through (x) and the in- creasing realization that Burkitt's tumour behaves as obstinately 266 as ALL put a seal on many a hope best stated by Burnet: 15 'To a great many people, medically trained scientists as well as laymen, the pot of gold at the end of the rainbow of medical research is the discovery of the cause and cure of cancer.'

Modus Operandi of Success

A word about the essential mechanism of the success, whatever, against ALL: A patient with a completely blocked esophagus because of cancer would die in a few days - not of cancer, but of starvation, as he would even if the obstruction were by a stricture or a foreign body. Treatment does not tackle the cancer, but the obstruction caused by it, assuring thereby a flow of nutrients, and a lease on life unham- pered by the threat of starvation. Similarly, what therapy does in ALL is to remove or minimize in a small percentage of patients, the ob- structions/compression of other normal tissues, in the bone marrow, brain and elsewhere, to the point of allowing life to continue, with no change in the basic pathology. It is important to realize that the same cellular force that makes leukemia cells continue multiplying regard- less of the therapy also sees to it that normal cells follow suit to popu- late vital tissues of the body so as to allow the patient to survive and be reckoned as 'cure' or 'remission.' All told, ALL success is an ex- ample of palliation - the crowning glory of all forms of cancer therapy.

Yes, it is Useful to Cure Cancer

'Yes,' said the great Metchnikoff, 99 'it is useful to prolong human life.' And, despite the blatant iconoclasm of this chapter against cancer therapy, it can be asserted that it is good to cure cancer and thus to prolong useful human life. Cure ( L. curatio, from cura meaning care) truly implies taking care of, and curing cancer means taking care of a cancer patient, as far as is possible, as best as is possible, and to the maximal well-being of the patient. The physician is undoubtedly the most important intermediary between one's disease and one's disso- lution, and the physician's benevolence can mean good life until death. Yes, it is good to cure cancer.

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