THE OTHER FACE OF CANCER

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CANCER: A PERSPECTIVE

A s regards cancer, the common man is at the mercy of medical man and the press, both thriving on the paradoxical combination of scare-mongering and cure-propheysying. Needless to say, the various cancer societies represent the best, or even the worst of the above two forces.

The medical double-speak on cancer is not commonly perceived by the layman. On the one hand, cancer is described as the greatest bugaboo of man, 163 and as a formidable problem almost beyond the comprehension of the human intellect. 164,165 On the other hand, prom- ises are repeatedly made of the victory against cancer, promises which have reached their climax 166 with the formation of an agency for the outright 'conquest' of cancer. A telling example of medical double- speak may be found in an authenticated, voluminous recent text 167 on cancer: In the preface, the editors pontificate that, 'Several types of human cancer that were hitherto fatal diseases have been cured by drug treatment.' Inside, an authority 168 on drug therapy describes cure by drug therapy as 'purely theoretical, since none of the known anticancer drugs has met the conditions for its full realization.'

Due to the persuasive power of the printed word, the press controls lay thinking on cancer. Describing 14,22,169 cancer as a totally mysteri- ous, totally inexplicable and total evil, silent preventable killer is com- monplace, occasionally exacerbated by rank paranoia: '... a savage cell which somehow... corrupts the forces which normally protect the body, invades the well-ordered society of cells surrounding it, colo- nizes distant areas and as a final to its cannibalistic orgy of flesh con- suming flesh, commits suicide by destroying its host.' 170

Having created needless fears over cancer, the press then proposes cures for it too. 'By far the best defense against cancer is an offense.' 14 But what kind of an offense? 'The public has been oversold,' Rutstein lamented: 171 'Thus, responsible publications cure cancer almost every week.' The pace of cancer research is so great, the press tells us, that by the turn of the century cancer will be no more, replacing thus the Homo sapiens by the Homo longevus enjoying 'life without the prospect of death.' 172 Dawe 18 of the American National Cancer Institute thought that the best analogy of cancer was man himself, proliferating and plundering. Cancer then will go; cancerous man will stay for ever!

Who guides the press and how? The scientific community is educating the press, so that the press can guide the public. 173 For example, every year the American Cancer Society sponsors 'science-writers seminars.' These seminars resemble one very long press conference rather than a series of serious discussions, boosted as they are by lengthy lunches and dinners. The Cancer Society apparently believes that there is a connection between a spate of "good-news" cancer stories and the success of its fund-raising drive.' 173 The Indian Cancer Society, 169 in a full two page press release, on February 17,1978, in the style of the American Cancer Society (see below), declared cancer as one of the most curable of all diseases, only to add that 'work is lagging behind for want of funds.' Individual scientists are not exempt from this ploy. A few years ago, Dr. Robert Good, adorning Time 174 magazine's cover, gave a big story inside it, thus testifying to his 'ability to attract research funds and keep his name before the public.' 8

Greenberg 175 exposed the American Cancer Society's claim about cancer's curability. He 44 quoted Davis, the ACS Science editor: 'Con- sider the other major death-dealing diseases among which cancer rates second: heart disease, stroke, influenza and pneumonia, dis- eases of early infancy, diabetes, cirrhosis of the liver, arteriosclerosis, emphysema, nephritis and nephrosis. Cancer is indeed one of the most curable in the country.' Yet, cancer is most curable, because all other leading diseases are more incurable than cancer. The medical establishment, indeed, never had it so bad. Despite the 'remarkable technical virtuosity' of modern medicine, it has made hardly any change in the adult life expectancy in the USA, in the last twenty years. 176

Confusion worse confounded! Such may be the feeling of the reader on perusing the foregoing, and on perceiving that the earlier chapters of this book, and the author's larger work The Nature of Cancer ,6 are uncompromisingly critical of 'almost the whole of contemporary can- cer research and cancer treatment.' 177

A solution to this seeming confusion lies in a perspective on cancer, an understanding of it that stands by us day after day, regardless of the chameleonic nature of cancer research and reporting. The understanding of cancer - cancerrealism - apart from offering the delights of studying cancer as an interesting biological phenomenon, can also help towards (i) economizing on cancer, (ii) despecializing cancer, and (iii) accepting cancer as a facet of life in general and a probable part of one's own self, in particular.

Understanding Cancer

A Herd Feature

Cancer is remarkably constant as a herd feature. 'Anybody who spends a little time brooding over the statistics of cancer must be struck by their unexpected constancy. From year to year the figures for each form of cancer show remarkably little variation.' Having so general- ized, Glemser 22 cites exact figures: 'Here there are 5,355 cases of cancer of the pancreas one year, 5,427 cases of cancer of the pancreas two years later - almost the same number. Or in another country, there are 218 cases of cancer of the pancreas one year, 221 cases of the pancreas the following year.'

Sir Thomas Browne, the author of Religio Medici , compassionately opined that 'the mercy of God has scattered the great heap of diseases, and not loaded any one country with all.' Cancer occurs everywhere, but in excess nowhere. A high incidence of cancer in one organ in a given country gets balanced by a low incidence of cancer in another organ. Segi and co-workers 178 in their report on mortality due to cancer at selected sites in 24 countries for the year 1962-63, placed Chile first (among all countries) for carcinoma of the uterus and of the stomach in females, second for carcinoma of stomach in males, twenty-fourth for leukemia in males and twenty-third for the same in females. They 178 placed Israel first for leukemia in males and females, and twenty-fourth for carcinoma uterus. In the global scatter of cancer incidence, 179 India shows the highest incidence of cancer of the mouth, pharynx and larynx, but is down below the other countries in the incidence of other cancers.

There are other implications of cancer's constancy as a herd feature. Geographically adjacent countries present startlingly different statis- tics. Ireland, barely 60 miles away from England, has 10 times more cancer of the lip than England, with reversal of the rates for cancers of lung, breast and uterus. On the other hand, countries poles apart present comparable cancer incidence - lethal prostatic carcinoma shows nearly equal incidence in Canada and New Zealand; women in Scotland and the USA have similar death rates from carcinoma of the colon and the rectum.

A large part of the so-called geographic variations in cancer of differ- ent organs is more racial than geographic. For example, as Khanolkar 180 stated: 'Now, what is remarkable from a cancer point of view is that the most common cancer in Hindu women is a uterine cancer. But with the Parsi women the most common cancer is of the breast...

Environmentally, their conditions appear to be the same. What is so interesting is that we find some cancers more common in certain groups of people than in other groups living in almost identical circumstances.' While Parsis have a high incidence of breast cancer, they have 'an exceptionally low incidence' 181 of other cancers.

The impartiality with which cancer affects mankind the world over, the constancy of its occurrence at particular sites in a country year after year, its 'startlingly different statistics' 22 for geographically adjacent countries,. and equally startlingly similar statistics for countries and people poles apart are all indicators of cancer as an integral human/ herd feature that has nothing to do with all the postulated cancerogens. The International Agency for Research on Cancer (IARC) Lyon, France, works on and publishes continental data on cancer to get clues to the causation of cancer on the basis of 'risk differentials,' 182 which in simple terms means an explanation for the high incidence of oral cancer in India but not in Japan. The IARC fails to mention that reliable- year-after-year data on cancer in a country or in a population, and never refers to the fact that if there are 'high differentials,' there are compensating low or very low differentials, as well.

Summarizing, one could say that cancer is, even at the human level, a discernible universal feature that is independent of the presumed cancerogens, and is impartial in its global sway. Cancer is a part and parcel of mankind.

At Individual Level: Intrinsic, Time-governed, Senescence

Though you drive Nature out with a pitch-fork, she will find her way back to triumph in stealth over your foolish contempt .

- Horace

Cancer is intrinsic : The intrinsicality of cancer implies that it is the individual's developmental programme that determines whether a cancer would occur. If it is not a part of his programme, nothing can cause it; if it is, nothing can prevent it.

Cancer springs from one's own flesh and blood. This very fact renders the above Horatian aphorism relevant to human cancer. All therapies put together cannot drive out Nature, manifesting itself as human cancer.

Cancer is time-governed : Man and animals are four-dimensional en- tities, with time as the fourth dimension. In the words of Portmann, 183 animal life, from its very start as a zygote formed by the union of the sperm and the ovum, is configured time. Put simply, all bodily changes of growth and decay occur along a pre- set programme, the programme unfolding with the passage of time. It is this time-governedness of cancer which determines the occurrence of an esophageal cancer in a boy aged fourteen years, or a man aged ninety-four years. The time of such occurrence is normally distributed .

Portmann, 183 talking of insect metamorphosis, observes that 'the spe- cific formation of the mature organism is prefigured in the egg, though in what way we do not yet know,' Foulds 3 refers to such pre-program- ming by animal life as a decision in advance of performance. Portmann continues: 'We have spoken of the insect, but we are all aware that such temporal processes are embedded in our own life.' Cancer is a temporal process, its programme already embedded in an individual and manifesting itself on the aging of the individual. The pre-program- ming is once again akin to what Foulds describes as the general phenomena of decision in advance of performance, both affirmatively and negatively. The former is exemplified by a puritanical non-smoker ending up with a lung-cancer and the latter by a chain smoker smoking his way joyfully into his nineties without any cancer, of the lung or anywhere else in the body.

A corollary of cancer being a part of the temporal unfolding of an indi- vidual is that like the unidirectional time-arrow, it is irreversible. No case of cancer, despite widespread folklore, has ever fulfilled the cri- teria of being labeled as spontaneously regressed or cured. 184,185

Peregrine Laziosi, an Italian monk who lived from 1265 to 1345 A.D., was supposed to have, in his early age, a huge cancerous mass on his leg which disappeared overnight after he desperately prayed to Christ to spare him the amputation. St. Peregrine, O.S.M., the patron saint of cancer patients is often invoked for alleviation and cure of cancer, for which he is best known in Austria, Bavaria, Hungary and Italy. 186

Can the occurrence of cancer, in an individual, be advanced in time, by making the body age faster? All cytotoxic agents - including X-rays and cancer drugs - are known 187 to accelerate the process of aging and senescence thus making a cancer appear earlier. Yet, if cancer is not a part of the individual's programme, such accelerated senes- cence of an individual means the earlier occurrence of the other dis- eases, but not cancer. The much-dreaded X-rays (including those that flow on to female breasts from the widely used mammograph) do not cause cancer, but make the cancer appear earlier. In this light, all the so-called cancerogens are 'accelerators of a process that is inherent in the animals,' 188 a mechanism discernible from the advancement of the time of cancer occurrence in animals 188 and humans, 189 and best expressed by the title of an article - 'Modus operandi of carcinogens: Mere temporal advancement.' 190 There is pithy neologism for cancerogens - they can be called cancer-preponers . 6

Cancer is a form of senescence. 'In fact, death is not natural at all. It's really an avoidable mistake.' Fred Stewart 191 has envisioned the dis- covery of The Methuselah Enzyme that would 'desenesce' the human body and make the afore-quoted anti-death hope a reality. With such an enzyme, the human body just would not senesce. However, Hans Selye, 192 writing in 1965 on 'The Future for Aging Research' as the concluding chapter to Perspectives in Experimental Gerontology as- serted that 'aging is essentially an ineluctable manifestation ' of the entropy that affects both the living and the non-living, and that sci- ence does not have any evidence to pin its hopes on some 'desenescing' enzyme. If death is inevitable and senescence is in- eluctable, then surely there is some basis to link the two: Senescence is the necessary prelude to an intrinsically-timed ontolysis.

If death is the ultimate function of individual life, death eventuating processes - cancer, vascular diseases - assume a physiologic role. Walter Cannon would have called this the biolytic / ontolytic wisdom of the body. Senescence resulting in death is not the outcome of a 'loss of programme,' 193 or a 'meangingless fade-out of genetic pro- gramming.' 5 It is an individual-specific, herd-serving, biolytic programme that is, for the individual, no less important nor less pur- poseful than the biogenic forces that fashion his being and the biotrophic forces that make him grow and exert his ability to survive. 'Why should a purely chemical process in a substance like collagen which has essentially the same composition in all mammals, move faster in some species than in others?... Senescence takes a gener- ally similar form in each species, whether judged by the physico-chemi- cal changes in collagen, the incidence of degenerative changes in blood vessels or the high incidence of malignant disease... The es- sence surely is that there is a genetic "programme in time" laid down for each species. There must be a biological clock and a means by which a series of processes can be made to occur earlier or later according to the expediencies of evolutionary survival.' 5 Cancer is but one of a series of senescent forces.

The pantrajectorial occurrence of cancer, from intra-uterine life to old age in man, has prevented it from being called a senescent process, as such a process for reasons etymologic, is expected to occur only in a senile individual. Senescence has been defined as an intrinsic process that increases the probability of the death of an individual. 5,24,193 Cancer, at whatever age it occurs, is an intrinsic process that increases the probability of death, whether it be in a child of two years or in a man of eighty years. In fact, its function of heightening the probability of death is more severe when it affects a young individual. In an old person, multiple, mild or moderate senescent processes produce an effectively lethal aggregate. Strehler 193 has put down, as criteria of senescence, intrinsicality, progressiveness and deleteriousness. Now, a child dying of cancer dies of a senescent process. It dies of a pro- cess that was intrinsic, deleterious and progressive and which when the child was alive had contributed to the increased probability of death. Nelson's 194 characterization of diabetes mellitus as a disease with wide age range - 'infancy to old age' - during which the disease may manifest itself, should force us to revise our thinking on senes- cence : If cancer and diabetes mellitus in old age are looked upon as senescent manifestations of aging, why should not the same in young age or even in infancy, be considered as anything but forms of senes- cence?

Summarizing, the hypothesis that cancer is an intrinsic, time- governed, senescent process is a gestalt view on the nature of can- cer. The intrinsicness does not admit of a cancerogen. The temporal nature accounts for the occurrence of cervical cancer in a young girl, and in a woman of seventy years; the time-governedness does not permit regression of cancer, a corollary fully substantiated by cancer- ology; the temporal nature allows the so-called cancerogen to be, more truly, a cancer-preponer. Cancer's senescent nature places it as one of the numerous pre-death forces; the senescent nature ex- cludes cancer as being necessarily a lethal process.

Who Kills Whom?

Foulds 3 has deplored the popular usage of 'military terminology' for cancer, like calling it killer, slayer, enemy and so on. The compelling reason for not calling cancer by such epithets is the confounding fact that, so often, an evident cancer cannot be held responsible for a person's death. Even in the book militarily- entitled Seeds of Destruc- tion , 195 the very first chapter speaks of the non-role of cancer: 'Can- cers are generally not in themselves fatal; that is, with rare exceptions they do not produce toxins or otherwise kill the host directly.'

On the basis of vast survival data of cancers treated and untreated, Waterhouse 196 was inspired to suggest that the diagnosis of cancer should not deprive a person of the benefit of insurance on his life. This accords to cancer an integral part in one's living, without pointing at it the accusatory finger - You are the killer! Patients having cancer, however, do die, if not of, then with their cancer. Many an older indi- vidual with chronic leukemia dies with the disease. 51 Jones 11 has alluded to the undefined physiological systems that produce death of the patient, and along with him or her, of the cancer. Who kills whom?

Cancer is Trans-Scientific

The liver cell is more like a typical cell, with no morphological features that make it extraordinary. 197 Yet, it is 'an extremely advanced indus- trial chemical plant.' 198 The liver cell has been cited here to emphasis the point Smithers 71 made about the cancer cell - both have no defin- able structural entities, and are only organs of behaviour . The cancer cell goes a step further. Liver cells from different animals look and behave similarly; cancer cells don't. Every time a cancer is formed, speciation occurs - a new species is formed as it were, unprecedented, unparalleled, unrepeatable. Cancerology's outstanding limitation is its ignorance on its leit motif - the cancer cell.

Weinberg 154 calls a question 'trans-scientific' when it can be asked of science, but which cannot be answered by science; such a question transcends science. The causality / curability of cancer is one such question. Despite its claims to the contrary, cancerology is a non- science . 199

'A disease is not an entity.. When the organism is incapable of resis- tance, as in cancer, it is being destroyed at a rhythm and in a manner determined by its own properties ... Disease is a personal event. It consists of the individual himself. 200 This statement by Alexis Carrel adds a further individualistic note to the 'trans-scientific' nature of can- cer. Note that Carrel talks of the organism's destruction, but the man- ner and the rhythm are determined by the organism's own properties. Cancerology thus faces a two-fold uniqueness - of the individual whose biological trajectory is predetermined and unpredictable, and that of the cancer. One more element can be added to this helplessness.

Towards studying the causation of cancer, cancerology has never been able to 'cause' a cancer when the cells or the animals had decided otherwise. Whenever it has claimed to 'cause' a cancer, the fallacy has been of post hoc, ergo propter hoc.

Given all these crippling limitations, it is easy to understand why cancerology has not been and will not be able to do anything against cancer, except studying it as a biophenomenon. Here lies the sav- ing grace. Cancer, in many of its facets, is comprehensible, and its behaviour is predictable at a herd level. Science, etymologically means knowing, not doing. Cancer is not trans-science if we aim at understanding it. It is so, if we want to manipulate it. More correctly, isn't cancer trans-technique? A part of Homo-sapiens , but not ame- nable to the Homo technicus ! One more, of the Illichian Limits to Medicine ! 201

Economizing on Cancer

Scientia est potentia; knowledge is power. The knowledge that can- cer is essentially non-diagnosable and non-treatable can, as a con- cept, propel us towards not doing in cancer. Munsif, an eminent Mumbai surgeon, was fond of aphorizing that, a good surgeon is one who knows when not to operate . What medical man needs to learn, in today's technicalized scene, is when not to act. This movement to- wards inaction in medicine is gaining momentum: Malleson 202 asks: Need Your Doctor Be So Useless ? Illich diagnoses Medical Nemesis . 201 Lord Platt's autobiography Private and Controversial 203 abounds in 'how to avoid' modern medicine.

Barbara Culliton 204 has recently reported, in Science , on the Breast Cancer Detection Demonstration Project conducted jointly by the National Cancer Institute and the American Cancer Society, employ- ing mammography, biopsy and surgery. Pointing out that mammogra- phy may diagnose what it had better not, Culliton puts a poser: 'The perplexing question, misdiagnosis aside, is whether surgery and fol- low-up therapy is really necessary.' To buttress the above, Culliton alludes to a study on prostatic cancer, showing that many a prostatic cancer does not bother its carrier. 'The implication is that one would have done these men no favour by treating them for a disease that was not causing them any problem.' A paragraph from the author's book on cancer, 6 published in 1973, deserves repetition here. 'Doing nothing - neither diagnosing nor treating unless compelled by a can- cerous patient's dis-ease - is the highest form of non-empiricism, non- arbitrarism, a kind of I-respect-you- (the patient)-and-Nature creed. It is refusing to interfere backing the refusal by a well-deserved assur- ance or discreet resignation. Agreed that there is never nothing to be done , 165 but this "never nothing" should be, whenever warranted, a Jeffersonian "pious" fraud. It cannot be overemphasized that a doctor is an adviser first and foremost, a doer only when the situation dic- tates. Should a patient ask him whether the former could be a Ulysses 205 in the world of medical investigations, get killed by chemo- therapy, or fall off the Golden Gate Bridge, the doctor's advice should be an assertive "No", for which the patient should neither deny him his fees nor drag him to the court of law.'

The realization that the path of Mary (one of contemplation and inac- tion) is preferable to that of Martha 206 even in cancerology, can mean a lot of saving on the psychic/somatic human cost, on animals and as a payoff from these on the hard cash spent on the overall problem of cancer.

Sparing the Human Psyche

The EKG (ECG) machine, a cardiologist commented, has done more harm than the atom bomb. The harm is in terms of the cardiac neuro- sis that the machine breeds. Christiaan Barnard 207 talks of the EKG's (ECG) 'electrical squiggle' transforming happy individuals with a pur- pose in life, into frightened, unhappy creatures of despair. Harrison 208 remarks that physicians suffer from EKGitis, and Heaven help their patients. Kraus 209 rightly said that 'Diagnosis is one of the commonest diseases.' Marcel Proust 210 lamented that for one disease that doctors cure, they produce a dozen others in healthy individuals by inoculat- ing them with an agent a thousand times more virulent than all the bacteria in the world, viz . 'the idea that one is ill.' Iatrogenic (iatral) diseases, it is commonly believed, 211-213, can be produced only by treat- ment. It needs to be appreciated that diagnosis itself can be an iatro- genic disease.

Diagnostically produced dis-ease is a major problem in cancerology. Despite the fact that the Pap smear, as of today, has doubtful 214 utility towards diagnosing/preventing cervical cancer, the Pap industry flour- ishes. The terms employed by the cervicologists are indiscreet, to say the least. In a series in which no definite cancer was found, the article had the title 'Positive cancer smear in teenage girls,' 215 and carried an exhortation: 'A description of the findings in seventy-seven girls who were less than twenty years of age when they were first discovered to have a positive cancer smear should support the contention that no age limit can be imposed on the application of the cancer screening method: if a girl is old enough to have a vaginal examination she is old enough to have a cervical cytologic examination.' Is this not diag- nostic vehemence, diagnostic iatrogenesis? The problem is no differ- ent for the breast, as Culliton 204 found (see above). All this diagnosing breeds what King 216 calls iatrogenic non-disease , wherein the physi- cian treats his patient for a disease which he has diagnosed but which does not exist. What if it does? We have by now been able to evolve an understanding that if the cancer does not dis-ease, nothing, not even diagnostics need be done, thus saving on all the investigations that otherwise necessarily follow.

Sparing the Human Soma

Having made a diagnosis, treatment is not a must. If the cancer dis-eases, the minimal need be done. Today, mere lumpectomy is fol- lowed by results as good as those obtained in breast cancer after radi- cal surgery. 6 Such minimal therapy is applicable to other cancers - pros- tate, 217 stomach, 140 pancreas 218 and so on. 6 Cancerologists are not ex- empt from treating 'people as things,' to earn more money. Over 200 years ago, 103 cancer operations were done more for personal gain than for the patient's benefit; things are not altogether different now. 219 The amount of 'unnecessary surgery' 219 today vindicates Shaw's attack on the 'pecuniary' interests of the surgeons. Surgeon, heal thyself!

Besides the mundane consideration of money, of greater importance is the sheer physical price that the human body must pay every time therapy for cancer is given. 'Doctors,' a cancer-patient-turned writer complains, 'play God with my body and life.' 220 Surgery, of necessity, mutilates; chemotherapy and radiotherapy destroy many a normal cell before killing a cancer cell; hormone therapy can mean earlier death from cardiovascular disease, 217 immunotherapy can mean the wors- ening of a cancer. The one dictum that all therapists can safely follow is - Less is more.

'Cancer nostrums are big business. They thrive because truly effective drug therapy had not yet been achieved.' 221 When nothing really works, everything can be supposed or shown as working against cancer; and hence the current 'Laetrilomania'. 222 Laetrile, or the anti-cancer vitamin B-17, is condemned as being neither anti-cancer, nor vitaminish, but a money-making fraud, that is at best an expen- sive and cruel hoax, and at worst dangerous. 220,223 Laetrilomania is a classic illustration of people's faith that something can always be done against cancer. The breeders of this faith are the leaders and the institutes interested in cancer research who, now and again, 'overwhelm the public with electric-guitar-like-clatter in extolling the progress of conventional cancer research.' 222

Sparing Animals, Cutting Down Research

Not one 'cause' of human cancer has been found by animal experi- mentation, 18 not one cure either. 6,23 All that the study of cancer in ani- mals teaches us is that the ways of cancer are as 'protean' as the ways of life in all its forms. 224 The SPCA would be fully justified in asking for cutting down of research on animals, on incontrovertible cancerological grounds.

Cancer research is what anybody does anything in the sophisticated field of genetics and molecular biology. 15 An editorial 225 in the BMJ posed a question - 'How relevant is present cancer research?' The editorial asked for an 'agonizing appraisal' since it was becoming clear that money spent on cancer was going down the drain. Smithers 71 characterized cancer research as a great field for gathering bric- a-brac , one that has lacked not funds but direction. A piece that ap- peared in The New York Times , 226 in a way, typifies cancer research; 'A controversy has arisen over a prominent researcher's purpose in conducting an experiment, in which he induced cancer in a small group of rats. The Federation of American Scientists, a public interest science group has charged in its monthly newsletter that the scien- tists conducted the tests merely to make a satiric point. The scientist, Dr. George E. Moore of Denver General Hospital, produced the cancers by inserting sterilized dimes into the peritoneal cavities in the rats' abdomens. Dr. Moore and his collaborator, Dr. William N. Palmer, published their findings in August in a letter headlined, "Money causes cancer; Ban it."'

Cancer research as yet has meant, to use Arley's words, 227 that more people live on cancer than die of cancer. What else could it be, given the odd mixture of the Promethean zeal, the cancerophobia, the politicization of cancer. 'I believe, however, that one might justly summarize American medicine as being based on the maxim that what can cure a disease condition in a mouse or a dog can, with the right expenditure of money, effort and intelligence, be applied to human medicine.' What Burnet 228 says about the USA, can be ex- trapolated to any other country. The Cancer Research Institute in Mumbai, founded in 1952, is a grant-in-aid-institution, under the Atomic Energy Establishment, Government of India. The organization has most things that a cancer institute would have. In a multi-coloured handout, meant for lay consumption, it gives all adulatory details including information on the Philips EM 300 electron microscope providing a magnification of up to 200,000 times for the study of nor- mal, precancerous and cancerous tissues. Science is supposed to be the human search for truth. Should not the institute have declared for once that like elsewhere in the world, all that the electron micro- scope has done against cancer is to magnify 200,000 times the human ignorance on cancer?

Fundology of Cancer

The hypothesis is unencumbered by any supporting evidence. The budget is the only part of the application which seems to have any substance whatsoever.

- Anonymous

The above comment by a member of the National Institute of Health (USA) study section, on an application for funds, exemplifies what Hixson' 8 found out about cancerology - when ignorant of what to do, ask for more funds. There is the whole science of getting funds: 8,23,229 fundology is a good name for it. 'Faculty are immersed in administer- ing the grants acquired, and their prevailing literary exercise is the writing of grant proposals. In short, the academic life has become one not of reflection, but of action.' 230 An unwritten law guiding the above literary exercises is to ask for more, spend more than you have asked for and thus assure for yourself a greater and greater grant every 'next year.' In science today, a man gets known by the funds he begets.

The annual outlay, in the USA, for cancer research will soon reach the 1 billion dollars mark, and will have to be increased at the rate of at least 100 million dollars a year just to keep pace with inflation. 231 Money is where cancer is. Cancer has pizzazz, luncheons, theatre parties fund-raising luaus, glamour, and 'in actual dollars and prestige,' even heart/mental disease cannot hold a candle to it. 232 Berman 232 points to the biggest risk in this game - 'what will they do if a cure comes out of it?' They need not worry; cancer will not let them down. Public under- standing of cancer may.

There is in the world of cancerology the all too common human failing of keeping up with the Joneses. A linear accelerator acquired by one institution is soon put to shame by a bigger accelerator at another. Berman 232 describes how, when something happens to a bigwig, insti- tutes jump in to make capital out of it. The President of India, Sanjiva Reddy, was discovered to have a lung tumour. With the usual fanfare he was flown to the Mecca of cancer research - the Sloan-Kettering Institute, New York. Somehow, the Government of India was made to understand that this had to be done, because India didn't have a linear accelerator. India already had one, working. Someone protested, but his voice was drowned in the din of the Establishment. The President's illness is expected to leave the legacy of the prestigious linear accelerator to the major cancer centres in India.

The USA spent 15 billion dollars directly or indirectly on cancer for the year 1968. 233 In 1994 the total bill for health care is expected to ex- ceed billion dollars a day. 234 Surely, a sizeable part of this must be for the diagnosis, rediagnosis, treatment and retreatment of cancer. Per- haps the USA can afford it. But what of India, Pakistan or Egypt where the majority live below the poverty line? Many an Indian, capable of leading a useful life for himself and his society, goes begging for treat- ment - be it for tuberculosis, leprosy, chronic poliomyelitis - for want of funds, while cancer research and treatment, with all its sophistries, go on at the major centres in Mumbai, Delhi, Kolkatta and Chennai, where they toe the line drawn by the affluent West. The Indian Cancer Society 169 itself, in its birth, was 'inspired by the monumental service rendered by the American Cancer Society.' No wonder we are out shopping for linear accelerators!

Despecializing Cancer

There prevails in specialized institutes an air of 'we-know- everything- about-the-disease.' Such arrogance is the outcome of a constellation of factors - (i) after all, specialization is the order of the day, (ii) being specialized , the institute and its men are most sought after from within and without the country, (iii) the diseasophobia gets tactfully built up by the institute, its peripatetic men, and the affiliated societies, and (iv) the Government's and the public's gullibility is that more funds to a specialized institute makes for more cures.

The outcome of the above specialized-institute-syndrome is twofold:

(a) the inevitable 'wiser-than-thou' attitude of the specialists who let the people know their designations and degrees tactfully through the media, and (b) the long waiting lists for an appointment, admission, operation, with the resulting humiliation, sense of despair, anxious- waiting on the part of the patients and their relatives. Our concern here is with the latter point.

With cancer, the most feared name among diseases, it is natural that people seek the speciality centres. Over the year we have witnessed commendable and voluminous therapeutic work on cancer done by non-specialized 'general' hospitals. The specialized cancer centre in Mumbai, the Tata Memorial Hospital does less work on brain cancers than the 'general' hospital (to which the authors are attached) with a neurosurgery department that has become a referring centre for brain cancer cases, even those from outside Mumbai. That is not all. The diagnostic, histopathologic, and autopsic studies on cancer in general hospital are also significant. What is most important however, is the fact that a cancer case treated in a general hospital, fares no worse than when treated at a specialized centre - a truth that allows global verification. Let us despecialize cancer for the following reasons:

1. Cancer therapy is 'lumpology.' A cancer therapist's chief function is to see a lump, to excise it by surgery and/or reduce its bulk by X-rays, drugs, or hormones.

2. The diagnosis of 'cancer,' i.e. the detection of the cancerous lump/ s is on the basis of clinical examination and investigations which are not outside the functioning potential of a general hospital.

3. Surgery forms the mainstay of cancer therapy and can be com- petently performed in most well-equipped general hospitals. What a cancer patient wants is the necessary 'diagnosis' and 'therapy' without loss of time. Despecializing cancer would help achieve this. How do we despecialize? The answer is simple: Tell the people the truth that it is not important who treats and where, but who and what is treated.

Accepting Cancer

The contemplation of things as they are, without substitution of imposture, without error or confusion, is in itself a nobler thing than a whole harvest of inventions.

- Francis Bacon

Bacon's invocation is pertinent, both for the cancer doctor and the cancer patient. The very term contemplation carries with it the mes- sage of the need for humility, patience, and restraint. To understand cancer is to accept cancer, with grace.

Cancer may easily be accepted as a part of mankind, but what when it comes to one's own self? Somebody has shown the way out. 220 Jory Graham, who has lost both her breasts to cancer that spread to her vertebral column and legs, took to writing a column inspiringly titled 'A time to live...' for the readers of the Chicago Daily News/Sun-Times. Like other cancer patients, her first reaction was, 'Why me?' Graham sought the answer in the existentialist creed that the universe as such is absurd and that her cancer was simply random luck . The three italicized words would have pleased Blaise Pascal, were he alive to- day; he would have realized that someone could adopt his probability child even when confronted by a personal tragedy. With such an ap- proach, Graham changed her question: 'Why not me?' And with that came a sense of power,. a realization that in the time left, 'she could still make choices and decisions.' Graham lived with her cancer, and what is more, she inspired others to do so.

Cancer Can Be Lived With

I submit that patients with cancer spend many more patient-years living than dying. There is really much more that could have been said about the patient living with cancer, and dying is certainly not the sole province of the person afflicted with cancer.

- Charles Tashima 285

A favourite theme of Sir William Osler was to live in daylight compart- ments. He epigraphed one of his addresses with the words of Robert Louis Stevenson:

Contend, my soul, for moments and for hours;
Each is with service pregnant, each reclaimed
Is like a kingdom conquered, where to reign.

Osler did not direct his positivism only to some cancer patients 'for whom time is running out.' He, like Kipling and Stevenson, pleaded that time is running out for everyone afflicted with 'an incurable dis- ease' called 'life.'And since everyone so incurably afflicted with a killer disease - ('The aim of all life is death.') 36 - lives, there is no reason why the presence of another killer disease, e.g., cancer, should mar an individual's zest for living, his joie de vivre . The title of Barnard's book HEART ATTACK - You Don't Have to Die 207 can be altered and enlarged to read as CANCER - You Don't Have to Die While You Are Alive . Despite affliction with a killer disease, it is possible to live long, be married, remarried, produce children, write medical textbooks, write soul-stirring, Nobel-prize-winning novels, and to make, like Louis Pas- teur, epoch-making medical discoveries. And all this despite the ines- capable impotence of medicine, so that the foregoing must be taken as evidence of the poorly appreciated benignancy of the so-called malignant diseases.

William Boyd, 51 the pathologist-author, had, in 1948, at the age of 63, mucus-cell adenocarcinoma of the parotid. For more than a quarter century thereafter, the medical world remained rich with Boyd himself and his books on pathology. His 1970 (eighth) edition of A Textbook of Pathology 51 was a book of 1464 pages, 908 illustrations, and a superb updated text. Alexander Solzhenitsyn had cancer in the mid-1950s from which he recovered. But the cancer did not dry up Solzhenitsyn's pen nor did it deprive him of a marriage thereafter to Natalya from whom he has two sons. And, let us note, all this and a Nobel prize, too, for literature despite a killer disease over decades ago. 'He has endured,' wrote Foote 235 while reviewing Solzhenitsyn's August 1914 , 'slave camps and near death from cancer. His experi- ences seem to have produced a strong belief in the existence of an inextinguishable sense of justice in human society and - despite the power and prevalence of evil (and cancer) - a spark of absolute conscience in the individual.'

Sigmund Freud had two killer diseases 'a coronary thrombosis' in his 30s and an oral carcinoma is his 60s. And yet, these two enemies within could not kill Freud who had to be helped to death by a friend , his physician/friend Max Schur who twice injected two centigrams of morphine to put him into 'a peaceful sleep,' for ever. In all Freud had 33 operations performed on him for his carcinoma. And yet he lived up to the end: 'His ability "to love, to give, to feel, stayed with him to the end," and his creativity endured; in his last years he wrote some of his most significant papers, none of them noticeably influenced by his illness.' 36

This refusal to stunt one's modus vivendi was shown equally well by Francis Weld Peabody. Peabody was in 'the last stages of malignant disease' and was taking a round of his ward when, to conserve Peabody's energy, his house officer suggested that he might pass by the next patient, who had a 'typical' pneumonia of the right lower lobe. And the inexhaustible Peobody roared: 'Of course, I shall examine the patient and listen to his chest; although I have auscultated thou- sands of lungs I have never heard two which sounded alike.' 236 Peabody died in 1927, but in the same year he published an impor- tant paper on pernicious anemia in the American Journal of Pathol- ogy . 237 It was fairly soon after his marriage to Laura that Aldous Huxley developed a metastasizing carcinoma of the tongue. But the 'killer' disease could not kill the philosopher's joie de vivre and he so lived, thought, and wrote that Laura Archers Huxley could write a moving biographical account of her husband, entitled This Timeless Moment 37 - a message capable of enlivening every moment of every man.

We have talked so far only of celebrities; we may also draw lessons from the lives of some ordinary men. Sanghavi, the father of a micro- biologist and the father-in-law of a consulting physician, of Mumbai, was operated upon in May 1967 for a carcinoma of the lower third of the esophagus, which, in the words of Boyd, is 'one of the most hope- less conditions.' With the nodes involved, 'guarded' prognosis was given. In the post-operative period, Sanghavi developed retention of urine from an enlarged prostate for which a prostatectomy was done on him in September, 1967. From that day, till March 1980 and aged 73, Sanghavi did not look back; he ate well, attended to his work, and but for tell-tale operative scars, was as normal as anyone else. The other case is of Dr. Adenwalla, a general practitioner who was oper- ated upon in 1961 for a colloid carcinoma of the cecum. Following the hemicolectomy, Dr. Adenwalla continued to practise till his death in 1984. In 1971 he was most satisfactorily operated upon for a carci- noma of the large bowel. Yes, it is possible to be struck by a killer disease twice, and yet to be able to refuse to say die.

'The border-line between sympathy and pity is very narrow,' writes Newton-Fenbow, 238 'and pity is corrosive.' It must be realized that the scare-mongering of modern medicine has created pitiable stigmata out of the so-called killer diseases. Diagnose cancer, coronary heart disease, or hypertension in an individual, and society starts looking at the individual with pity" Don't do this; don't do that. 'If one only makes a determined effort towards normality when one has to, then one finds (thank to the pitiers) an increasing number of very valid reasons why today no effort should be made but tomorrow - and when tomorrow arrives one is finally incapable of making any effort.' 238 It is the duty of the physician to spare his patient the burden of paralyzing pity and confusing do's and don'ts from the humans that surround him.

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