M aking prognoses is tantamount to prophesying. We do not know how authentic the prophetic role of a doctor is. If the authenticity can be proved, the doctor's right to prognosticate is justified; if not,
the physician can be requested to stop playing the prophet. In the widely publicized court trial, 121 the physician's prognosis was that Karen Ann Quinlan, the young American girl in a coma, would die soon if taken off the life-sustaining machines. Her parents pleaded to the court for taking the plugs off so that Karen could die. The court agreed. But Karen did not die. If the physician-prophets could be proved wrong in a case that appeared so clear to most of the people, how could they prove any where near right in cancer, surrounded as it is with so much uncertainty, diagnostic and therapeutic?
The State of Prognostic Art
The state of the prognostic art leaves much to be desired. 'Of the trilogy of disease, diagnosis, prognosis, and treatment, prognosis is the most difficult to evaluate. The accurate prediction of things to come is often most baffling, perplexing, and problematic. Caution is essen- tial. The less said the better. Remember that we are endowed with two eyes and two ears but with only one tongue. The implication must be apparent.' 122 This is but natural, for prognosis as a subject has been least touched upon in medical literature. In A Medical Bibliogra- phy compiled by Morton 123 and published in 1970 in its 3rd Edition, there are 7,534 entries dating back to the time 2250 B.C., of the great Hammurabi; of these, only one entry is on prognosis, viz.
Depraesagienda vita et morte aegrotantium by Prospero Alpino, pub- lished in 1601. In Familiar Medical Quotations , edited by Strauss 124 and published in 1968, there are more than 7,000 quotations on over 400 subjects - 'from Cathay's Huang Ti, five thousand years ago to present day opinions on transplantation and birth control.' On 'prog- nosis,' there are eighteen quotes of which only two are from specific works on prognosis; one from Hippocrates On the prognostics , and the other from a small editorial by Robbins, 122 published in 1961 in the Archives of Internal Medicine , and quoted from, as above. All told, medical prognostication is more of an art than a science.
Prognosis in Cancer
One who makes a prognosis in cancer, blissfully unaware of his limi- tations and rather too sure of the ideas of early and late cancer, in- dulges in two extremes: (1) offering hope when hope may not be ra- tional, or (2) presenting hopelessness when hopelessness may not be warranted. And he can get away with either. The first measure allows him to be condoned on the grounds of his benevolence; the latter measure provides a subtle defense for him, for rarely does a patient surviving longer-than-expected have the heart to find faults with his prognosticator. 'There are doctors who, to show their worth and to be sure of an excuse, make bad seem worse and of the worse make a disaster.' 125
The reasons why a cancer prognosticator feels so sure of himself are many. His diagnostic and therapeutic skills register advances every- day. His assessment of a cancer case is seemingly complete - clinical examination, endoscopy, an arsenal of investigations, and the find- ings at the operation.
Yet despite this impressive array of aids to prognosis, the prognosti- cator encounters unreliability, at every stage. What he has always thought to be an early cancer has rarely been so. He takes the small size of a tumour as his guide, but that cannot help him: The general assumption that all dwarf-sized cancers must be biologically young is no more valid than the assumption that all human dwarfs must be young because they are small.' 126 The mode of cancer growth ren- ders useless any attempts at detecting the silently growing tumours measuring less than half a centimeter in diameter.
Cancer cytology is highly arbitrary and therefore unreliable. Histology does not fare any better. 'Contrary to the experience of some work- ers, we have not found that the histology of biopsy specimens offers any useful guide to prognosis or management.' 104 This1970 generali- zation by Ho 104 - in whose series most cancers were undifferentiated - is similar to the 1960 generalization by Sutherland 95 that, at present, prognostically different cancers are often morphologically indistinguish- able. The grading and staging of cancers represent, the valiant efforts by prognosticators at playing the prophet, depending on apparently objective criteria; but 'a given carcinoma may be graded II one day and III next, or vice versa, depending on the functional tone of the gastrointestinal tract of the pathologist or the barometric pressure.' 127 And what if the grading were to be precise? Writing on the grading of the adenocarcinomas of the colon and rectum, Boyd 128 comments that while statistically it is possible to establish some agreement between the grade, lymph node involvement, prognosis, and so on, 'this does not mean that it is of prognostic value in the individual patient.'
Prognosis in cancer, like in other branches, is a judgement based on circumstantial evidence, but no judgement can be respected when the evidence is largely suspect. To the prognosticator , cancer is what and where he sees it. However, his detecting cancer at one or more sites is no guarantee that the cancer is not additionally present else- where. Moreover, what he sees as cancer is an independent, biologi- cally predetermined behavioural entity, that does not permit him to tell: What really is the cancer? Where else is it lurking? What will it do? And when? And when will the patient die of something totally different?
Despite such ignorance, an all too common pitfall is the urge to make favourable prognoses on the basis of 'early' treatment. It was as early as in 1936 that Nathanson and Welch 129 reported that in their series of breast carcinoma, 'patients with the shortest delay of the treatment have the worst prognosis.' Not infrequently, a prognosis of doom proves wrong, and the patient survives, showing that the prognosticator had seen a disaster greater than was in store for the patient.
Role of Statistics
'In individual prognosis,' Hyman 130 remarked, 'statistics function as a weather-vane. From them the practitioner recognizes the wind direc- tion; he knows nothing of wind velocity, or of weather conditions such as temperature, humidity or visibility.' The prognosticating physician is, by and large, unaware of the weather-vane-nature of statistics which come to him as definite, reliable, proved-correct-generation-after- generation figures in authoritative writings on diabetes mellitus, 131 coronary heart disease, 132 hypertension, 133 or various cancers. 20,134. The prognosticator has nothing to guide him in an individual case - for whom he can, at best, retrognosticate or be wise after the event.
Backed by an implicit faith in the truth of large numbers, the prognos- ticator finds it convenient to extrapolate the herd data to an individual, ignoring the fact that the extrapolation is fraught with Heisenbergian uncertainty. 'In biological problems, variable factors of considerable complexity often are present, the necessary consideration of which distinguishes biometry from statistology.' 135 Such warnings escape the eyes of the prognosticator and so he continues to prognosticate despite Heisenberg or McDonald. Even when he employs statistical prognosis, the prognosticator probably neglects cautionary state- ments often appearing at the very beginning of the text. 'It is true in diabetes mellitus as in other chronic diseases that the prognosis for the patient is extraordinarily individual.' 131 The cautionary note on an individual is followed by one on a group: 'Generalization with regard to prognosis may be based on averages in special groups and for special complications; nevertheless, wide variations are found in the duration of life and the presence or absence of diabetic sequelae within each group.' 131
How realistic would it be for the patient were the prognosticator to admit that all that he is offering prophetically is statistical! How unbur- dening would it be for the prognosticator to realize that, at the level of an individual he need not prognosticate at all!
The Need for Prognosis
Notwithstanding his crass ignorance on the whether, when, how, and, why of the art, the physician must prognosticate. Brooke, 88 writing on cancer, described prognosticating as 'perhaps the most important act in medicine.' And perhaps, this is true for altogether different rea- sons, namely to share with the patient and his near-ones the usually unacknowledged medical ignorance on cancer and to let the patient know that cancer can be as kind as it can be cruel. Set below are a few suggestions:
1. The time of prognosticating is the time to talk things over with the patient. It is the time to act as a patient's friend by providing him with the drive to dare the disease, and to live with it.
2. Prognosis involves exploring and exposing areas from where assurance can be had and destroying areas from where unwar- ranted fear stems. Cancer patients often live in depression and it is for the prognosticating physician to pull them out into living a yea-saying life that meets with the Kiplingian urge to fill every irretrievable minute with sixty seconds' worth of distance run.
3. Prognosticating includes protecting the patient against the tyranny of lay and medical articles rich in well-intentioned scare-mongering.
4. Prognosticating does not include,. despite Hippocrates, guilt- pointing and fault-finding. Carcinoma of the lung in a smoker, or carcinoma of the stomach in a gourmet, or carcinoma of the cer- vix in a woman who has loved life, is no Dostoevskian story of Crime and Punishment. The occurrence of a lethal laryngeal cancer, in that sage from Dakshineshwar, Ramakrishna Paramahansa - whom Wilson 87 calls a great mystic, a God-intoxi- cated saint - was certainly no retribution from a wrathful God.
5. Active Patient-Participation. What I do not know, is unfathomable. What I do know, is shareable. Our 'the-more-we-know-about- cancer-the-less-we-seem-to-understand-it' predicament has attained sufficient magnitude to enforce the prognosticator to practise the above code of conduct vis-a-vis his prognosee.
6. Herd-realism, normal distribution, Gompertz function, curves of disease-specific mortality, etc., are subtle and inexorable indica- tors of the fact that an individual, despite all his unprecedented, unparalleled and unrepeatable uniqueness, is herd-dependent with respect to many features. In his chapter on the 'Statistical study of tumours,' Willis 20 emphasizes that the age distribution of a sufficiently large series of cancer deaths, in a population, pro- vides 'a smooth ideal curve' of normal distribution. This normality of distribution is a herd-function, and, at an individual level, de- pends on the point of the curve one falls on so as to die of cancer at the age of eighteen, or ninety-eight years. To the patient set to die of cancer at eighteen, (as well as to his near ones), it is 'cha- otic' that he should be so 'victimized' by Nature. But if he and the others realize that his 'chaos' is a part of the orderly 'ideal' curve, the sense of persecution is likely to be minimized.
7. Prognostication in cancer should include retrognostication con- sisting in explaining to the patient that his cancer, dis-easing him now, has been with him for five to fifteen years. Further, that the earliness or lateness of a cancer lies in the mind of the clinician, and not in the cancer.
8. The patient's cancerrealism that he is harbouring a cellular phe- nomenon of which even the prognosticator is only as wise as he himself can make him an equally important participant in the fight against the disease. In the absence of such realism, the patient suffers from a sense of singular victimization out of the frustration that medicine and medical men are not offering him his due.
9. Prognosticating includes admitting investigational limitations and therapeutic impotence.
10. The cancer-can-be-cured syndrome is no different from the well- recognized ICCU (or ICU) syndrome. 6,136,202 (ICCU stands for Intensive Coronary Care Unit. The syndrome is suffered by heart patients admitted to the ICCUs, as also by the medical and paramedical staff attending to them. The ICCU syndrome sym- bolizes people's and medical men's faith in the marvels of modern medicine bought at an enormous psychic and monetary expense, without good done to anyone.)
The cancer prognosticator must see to it that his patient's body, mind and soul are not additionally burdened with the above syn- drome, and that the syndrome does not kill the patient's family while medicine is fruitlessly trying to save the patient.
11. 'Prognosis is a continual process that may extend beyond the patient's death, for the bereaved ones.' 6 This can go a long way towards assuaging the unhappiness, anger and bitterness of the patient's near-ones. 279
12. An excellent way of winning the confidence of a patient, while prognosticating cancer, is to allude to the not-very-uncommon event of the cancer-patient outliving his cancerologist: Evarts Graham, the famed St. Louis surgeon who introduced 'curative' operation for lung cancer - called 'Graham's operation' - oper- ated on a doctor who survived to see Graham dying of lung can- cer 'not diagnosed until it was too late to apply the operation that he had developed.' 280 Such an exercise in medical humility, whereby the healthy-looking physician admits that the diseased prognosee could well outlive him, may find a starting point in an old skip-rope song:
'Doctor, doctor, will I die?'
'Yes, my child, and so will I.'