THE OTHER FACE OF CANCER

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NOT TREATING CANCER

Of all the heresies that have been committed in this book so far, this may sound as the most unconscionable and unpardonable.

Yet the weight of the unheard evidence in favour of this heresy is too compelling to remain unheeded any longer.

The following case, personally known to the authors, is illuminating. Mrs. D., a dentist's mother, aged sixty-one had some vaginal bleed- ing, for which she was examined and was found to have carcinoma of the uterus with metastasis (spread) in the lower vagina. Prior to the diagnosis - or, rather prior to the treatment - she enjoyed good health, appetite and sleep, and could move about freely on her own. The cancer therapist pointed out that surgery was out of question and recommended that she be given chemotherapy. The patient pleaded that the disease did not bother her and that she was not keen on having anything done to her. The family did not relent and chemo- therapy was started. On the fifty day after chemotherapy, she felt very weak, lost her appetite, and had to be hospitalized. The chemotherapy course was duly completed, but the patient never left her bed until her death three months after the treatment, having lost all her appetite, sleep, hair, and her joie de vivre , which she had had in full before the treatment. The therapist, who treated Mrs. D. perforce knew that the treatment of choice, viz. , surgery, was ill-advised, and he resorted to chemotherapy for treating a known-not-to-respond cancer on the grounds that treatment must be given even if there was a snowball's chance in hell that the outcome would be good.

The knowledge of cytokinetics and mode of cancer growth, tells us that Mrs. D surely had had the cancer at least for a decade before there was any discomfort. And even after that, she was at peace with herself and pleaded for being left alone, but in vain. Mrs. D's case illustrates three points: (I) a patient not dis-eased by cancer may be left alone; (ii) the therapy should not be more diseasing than the patient's dis-ease; and (iii) care should especially be exercised while using cancer chemotherapy. The reason for (iii) should be amply clear from what follows: An eminent authority 100 on cancer chemotherapy has generalized that 'if an agent has certain biological effects, such as carcinogenic, mutagenic, or bone-marrow-depressant activity it merits testing for chemotherapeutic activity against cancer.' This learned statement ought to convey that all agents presented as anti- cancer were 'carcinogenic' to start with. An editorial 101 titled 'Second neoplasm - a complication of cancer chemotherapy,' annotating an article 102 describing the occurrence of leukemia as a complication of chemotherapy of ovarian cancer, should come as no surprise.

Cancer-realism

Cancerrealism is imperative for the right not to treat cancer. The basis for such realism is afforded by the relatively more benign cancers such as chronic myeloid leukemia and chronic lymphocytic leukemia, as well as by the relatively more malignant cancers as of the bronchus, breast, or nasopharynx. An integral part of cancerrealism is Hoerr's law, self-promulgated 278 in 1962: It is difficult to make the asymptomatic patient feel better . An obvious corollary to Hoerr's law is that it is very easy to make the asymptomatic patient feel worse, and such a person who is as yet not a patient, is best left untreated, best left unburdened by either diagnostic label or diagnostic proce- dures.

In1802, a committee of Scottish physicians wrote a memorandum 103 comprising questions and answers on cancer. This memorandum 103 was first published in 1806, and was reprinted, 'with full justification' in 1967. It may be taken as one of the most cancer-realistic works, published so far, being marked by subtle wit, sound common sense, remarkable dispassion, and brilliant invective. Lamenting the lack of 'an exact definition' of cancer, the memorandum observed: 'It has accordingly happened that a disease, which has been denominated cancer by one medical man, has not been allowed to be such by an- other; and painful and hazardous operations have been performed by some, which were not thought necessary ...' The memorandum also remarked: 'Tumours in the breast, of a considerable size, will often remain in the quiescent state for many years, even to the close of life, if not disturbed by injudicious treatment or extraneous injuries, of which the ancients were well aware. It therefore appears as improper to extirpate these as it does to suffer them to remain, when they begin to be disturbed and can be wholly removed.' The passage of a good 208 years, characterized by unprecedented research-attack against can- cer, has not done anything to add a word to, or subtract from, the Scottish wisdom. The above quotes bear thorough relevance even to modern times when (i) many operations are done when unwarranted, (ii) it is possible to live with cancer, for many years, and (iii) it is a silent-cancer-turning-symptomatic that calls for treatment.

Ho 104 presenting his experience on 'The Natural History of Nasopha- ryngeal Carcinoma (NPC), at the Tenth International; Cancer Con- gress 1970, remarked that the duration of the disease - over 97% of the NPC in his series were of the undifferentiated type - varies widely. With no specific treatment, or with radiotherapy, which is only pallia- tive, a patient may live from a few months to over ten years from the time of diagnosis. The patient with the longest survival of thirteen years was an Eurasian, who, all along his 'illness' declined treatment. After thirteen years with his cancer, he died at the age of seventy-eight of a heart attack.' And not so rarely,' we may recall Brooke's words, 88 'can- cer itself is overtaken by another disorder and beaten to the final post.'

The chronic leukemias offer frequent examples of cases living for long, when left untreated, or treated only when dis-eased. 105 'Many of the older patients may die with rather than from the disease.' 51 Asymp- tomatic patients should not be treated, however high the counts and however massive the enlargement of lymph nodes, liver and spleen. 106,107 Treatment itself may bring in rapid decline by precipitat- ing an acute leukemia crisis. 107 Stevens 108 describes the case of a patient who had lived with her leukemia for the duration of at least seventeen years and possibly twenty-eight years. She was in good health all along, despite 'extensive infiltration' of the bone marrow by leukemia cells. Asymptomatic, she was trapped into getting her counts treated by cancer chemotherapy for the last five years of her life; she then developed varied infections, and eventually succumbed to overwhelming recurrent pneumonia.

Durrant and co-workers 109 reported, in 1971, a 'Comparison of treat- ment policies in inoperable bronchial (lung) carcinoma.' They ran- domly allocated 249 patients, with inoperable bronchial carcinoma confined to the chest, to four different groups, each treated differ- ently. One group received no treatment until 'significant' symptoms appeared (the wait-and-see group). The other three groups received treatment whether or not they had symptoms at the time of entry into the trial, and were given radiotherapy, chemotherapy, or a com- bination of the two. The mean survival in the wait-and-see group was 8.4 months, whereas in the groups treated with radiotherapy, chemotherapy, or their combination, it was 8.3, 8.7 and 8.8 months, respectively. The group of patients whose anti-tumour treatment was delayed until symptoms appeared obtained as good palliation as those treated immediately.' The authors 109 of the report felt that their results offered no evidence that immediate treatment by radiotherapy and/or chemotherapy leads to prolongation of survival or to preven- tion of incapacitating symptoms in patients with inoperable bronchial carcinoma.

The we-must-operate/treat therapeutic diehards so insist on the grounds that enough is not known about the untreated diseases. 'On the contrary, if one bothers to scan the literature, there are ample articles on just this subject' 110 showing the 'natural course' of unoperated cholelithiasis, 111 of untreated breast cancer, 112,113 and so on for gastric/duodenal ulcer, 114,115 mitral stenosis 116 and cancers of esophagus, stomach, colon, rectum, liver, gall bladder, and pancreas. 117

The Painlessness of Cancer

An important cancerlogical reality is that all cancers from the time of inception, through five to fifteen years, to the time of diagnosis are 'discreetly hidden' 88 and painless. More importantly,many cancers continue to be painless even after being diagnosed at the primary or the metastatic site. It was the same painlessness of cancer that allowed a Mayo, a Wilkie, or a Dorn to continue to work peacefully up to the time the widespread and inoperable cancer was diagnosed, and death followed fairly soon after the open and close procedure. The Lancet 118 described oral cancer as an obstinate clinical problem, and lamented that more than half of all patients in England and Wales with intro-oral cancer, presented themselves at a late stage of the disease. Why at all, one may ask, should such a thing happen when a very small aphthous ulcer in the oral cavity can create hell for a patient through the trigeminal nerve? Why should the oral cancer not imitate the aphthous ulcer? The truth is that it is in the very nature of cancer to be painless during the major part of its existence in the patient's body. Like Nature, cancer is cruel but cancer is kind. And cancer is painless, because it is, teleologically speaking, meant to be so. A patient who 'neglects' a cancer does so because the cancer does not, for long, dis-ease him or her. Which city dweller 'neglects' a foreign body in the eye or an acute pyogenic abscess in the perianal region?

Not Treating Cancer

Let us now consider the problem of a woman with a silent breast lump: If it is non-cancerous (the chances being more than 2 out of 3), 119 nothing need be done. If it is cancerous, you are too late to do anything. A rational conclusion is that nothing, diagnostic or thera- peutic, should be done for this patient. Strange as this proposition may seem, it is fully backed by established cellular and tumoural cancerrealities. An old man found to have a hard but silent prostatic nodule on 'routine checkup' need not be benevolently dragged into the consciousness of having cancer. The diagnosis is, non-committally and correctly, a breast lump, a prostatic nodule, and the like.

It will be a great day for rational medicine when the physician ac- quires the right not to diagnose, and therefore not to treat, a cancer which is at peace with its owner. Outrageous as this proposition may seem, it pleads that the patient be spared mental death prior to the cancer's turning obtrusive on the patient's senses. It may be argued that unless the patient is warned in advance, he may be caught unawares by the disease. But the warning is unreliable - you tell the patient that he will live 'another three weeks, I won't guarantee you any longer than that!' 9 and he manages to live for many years. The warning is undesirable for it precipitates a sort of posthumous exist- ence with perpetual expectation of the worst, for the patient or even the physician-patient. The warning when expressly denied by the physician, does not spare a patient sudden cancerous or cardiac illness or death. The authors know of a general practitioner's wife, in her forties, declared by some eminent cardiologists of Bombay to be free from any heart problem, dying suddenly of a heart attack barely fifteen days after being given a clean bill of health. This is not an uncommon event, in big cities with big cardiac clinics, where a hu- man being elatedly walks out of the cardiologist's consulting room, with completely normal EKG (ECG), only to collapse to death from a heart attack, barely a few yards away from the clinic.

Cancer, for a long period, exercises discreet silence before dis- easing a person. S.J. Mehta, a staff member of The Tata Memorial Centre, was fit and working before developing symptoms that led to the detection of cancer that had spread to multiple sites without any trace of the primary source. 6 For Sir David Wilkie, 120 'then, in August 1938, at the age of 56, after a brief spell of declining health ... the X-ray confirmation of gastric carcinoma ... the end a few days later.' Knowing that the duration of undiagnosable and asymptomatic can- cer is pretty long, the cancers in the above two physician-patients must have remained 'discreetly hidden' 88 for many years before turn- ing symptomatic; and for all the time that the cancers were left undi- agnosed (and untreated) , both the surgeons were mercifully spared the Keatsian 'posthumous existence.'

Physicians, who contemplate the view that cancer may not always be treated would have to bear in mind, however, the modern litigious society comprising patients prone to turn litigant against the doctors on not getting what they paid for or were ready to pay for. As things stand today, medical, judicial, legal, and general public opinion would tend to hold unimpreachable a 'play-safe' man who treats every cancer case, but would not pardon a doctor refusing to treat until he absolutely must. The position of such a 'risker'can be rendered progresssively safe only by making the physicians and the public - lay, legal, judicial - swallow the insipid but helpful pill that no treatment is also a form of treatment. To help achieve this seemingly impossible aim, enlightened physicians can start an Anoci - Associa- tion of Cancer Therapists (AACT) who moto should be primum non nocere . The AACT ought to publicize the unrecognized and unsung benignancy of cancer, the unpredictability of cancer, the hazardous nature of all forms of cancer therapy, the 'damned-if-you-do' and the 'damned- if-you-don't' experience of all cancer therapists, and, above all, that even cancer permits of the patient being left alone. The AACT may eventually manage to get financial aid from government or other agencies by showing that AACT could mean a lot of saving on the enormous monies spent directly or indirectly on cancer every year, the whole world over.

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