' In my experience, for what it may be worth, it does not usually work out in the long run to be seduced into telling the untruth.' 286 This plea by a cancer doctor can be joined to a declaration made by a cancer patient: 'The time to be honest about cancer is now.' 287 And that has been the aim of the book - to present a gestalt view of can- cer. Such an approach reveals cancer not as the villain of the piece that deserves all the metaphors listed by Susan Sontag 288 but as an interesting, universal fact of biology that also affects humans. This is not easy, given the might and the seeming wisdom of the cancer societies and the cancerologists backed up as they are by senators, lobbyists, 'Benevolent Plotters', engineered columns in the media, and 'the somewhat naive but widely held view that science can make things come out as we would like them to be.' 289
Facts, however, are on the side of a person wanting to have a realistic approach to cancer. Cancer can be understood - by the lay and the learned - to the point of not fearing its occurrence, and should it occur towards making the most out of life and getting the best out of medical care. Toward this, we sum up here the epidemiology/cause, diagnosis, prognosis and the treatment of cancer.
The current epidemic 290,291 of epidemiologic studies on cancer draws its sustenance from the half-truth that tells you, for example, that can- cer of the mouth and throat has a high rate in India, without letting you know that this highness gets adequately compensated by low rates of other cancers. This is equally true in Japan or Germany, Tripoli or Timbuktu. In 1926 Cramer 292 pointed out that the apparently greater mortality from stomach and intestinal cancers in Dutch women was compensated by low mortality from cancers of breast and uterus, seemingly higher in English women. We reiterated this in 1973. 6 Burch 293 in 1976 reinforced this is to conclude that this global overall consistency of cancer in its incidence and behaviour reflects an intrin- sic human quality, for which no cancerogen need be incriminated. It is time we are cured 6 of cancerogenophobia. 290,291
Cancer patients are often overburdened with the guilt that their can- cer is a result of some acts of commission and/or omission. This need no longer be. Cancerologists must reassuringly exonerate their pa- tients of any such guilt in the style of Godwin-Austen, 294 an English consultant neurologist and an authority on Parkinson's disease: 'You must remember first of all,' Godwin-Austen 294 tells his patients in a special booklet, 'that Parkinson's disease has NOT resulted from some- thing you have done (or not done) in the past. It is NOT caused by overwork or overindulgence, and it is very unusual for Parkinson's disease to be related to injury of any sort.'
What can we say of cancer 'diagnosis' when it is now widely admit- ted 295,296 that such a thing is always a late event in the course of the disease! 'Diagnosis,' is necessary when a person comes with symp- toms. However, the various cancer screening programmes, most vehemently seen with reference to the breast and uterine cervix, seduce into the diagnostic mill a person otherwise completely at peace with herself or himself, and often foist upon the now-patient the diagnosis of cancer or a doubt to that effect. A psychiatrist 297 points out that the very word cancer implies, in the mind of the common person, 'pain, disfigurement, hospitalization, debts, inability to care for one's family, dirtiness, loss of sexual attractiveness or function, disability, and possible death,' a complex from which the most highly placed medical 298 men are not exempt. Susan Sontag 288 rightly points out that Karl Menninger has observed (in The Vital Balance ) that 'the very word "cancer" is said to kill some patients who would not have succumbed (so quickly) to the malignancy from which they suffer.' Not surprisingly, Martin Fischer 81 proscribed diagnosis to prevent a 'death sentence' being passed by 'a powerful physician' 299 on a 'powerless patient.' 299
Comfort 300 has described anxiety-making as a curious preoccupation of the medical profession; unwarranted cancer-diagnosis represents one such preoccupation. The so-called public awareness of breast cancer can mean panicked parents rushing with their frightened daugh- ters to the detection centres, where girls of 8-12 years of age, with asymmetrical growth of otherwise normal breasts, may end up with a permanent loss of breast because of misplaced diagnostic zeal. 301 Screening programmes - described in medical circles 302 as 'success- ful business ventures' and as 'frankly commercial' - have proved not only useless but scaremongering, be it for cancer or coronary artery disease 303,304 resulting in demands for decently burying them.
The essential non-diagnosability of cancer has foiled the technology and the machines of modern medicine. 'Most of the tools of a doctor used twenty-five years ago fit into a small black bag. Today the typical American physician owns or has access to $250,000 worth of diagnostic equipment... Whenever one tries to link the development of new technology with a coincidental improvement in healing, the answer is always the same. There is none.' 305 This media-assess- ment is endorsed medically. 306 Prognosis, the other gnostic part of clinical cancerology, concerns itself with what a cancer cell or a tu- mour will do to a patient. The help of technology and machines has also been marshalled toward this, with no gains. Computers have been used to analyze cellular features, 307 only to be plagued 6 by the computer-jargon GIGO - garbage in, garbage out. Graham's asser- tion that 'cancer is inherently unpredictable' 287 is not only so at the gross clinical level as she wants to imply, but at all levels. Regardless, la technique 308-312 presses on: the recent report 312,313 on predicting by 'at least three years' from now the right drug for a cancer patient by pretesting the drug on the patient's cancer cells grown in a petri dish, is oblivious (a) to the inherently non-specific, 314,315 toxic, 316 and essentially ineffective 317 nature of 'cancer drug,' (b) to the fact that in a handful 318 of cancers against which the drugs are 'effective,' the therapy is attended by unforeseen complications, 98,316 infections 319 and above all frightening uncertainty,' 98 (c) to the ability of the one and the same cancer to be made up of more than one cell clone, 6,20 and finally (d) to the penchant of cancer cells to develop, in no time at all, resis- tance 274,320 to a given drug.
While on prognosis, a word or two may be in order on the prognosis of cancer research, itself. Despite such pessimists as Bier 321 - 'all that we know for sure about it can be printed on a calling card,' Burnet, 5,15 and ourselves, 6 the air is full of tremendous optimism, as may be dis- cerned from Lewis Thomas's latest assertion: 322 'What is new in medi- cine is the general awareness that these (senile dementias, arthritis, cancer) are biological problems and that they are ultimately solvable.' Cancerology never had it so good. Greenberg 323 has char- acterized such proclamations as 'reminiscent of Vietnam optimism prior to the deluge.' Hope, however, springs eternal in the human breast, and cancerologists are no exceptions.
'A common cancer hospital witticism, heard as often from doctors as from patients, is "The treatment is worse than the disease." 288 Why should doctors, of all, let out the truth? They, in fact, do not do so as often and as loudly as they should, but their actions, taken to mitigate their own cancer, betray the truth that they know better the ravages of cancer therapy. Many doctors have 'a strongly pessimistic attitude about treatment of cancer.' 297 No wonder!
A study 324 undertaken to determine to what extent doctors, faced with the prospect of having a cancer, 'practiced what they preached,' revealed some startling facts: Doctors, the 'disappointed' investiga- tors generalized, (a) do not bother to seek an early diagnosis, (b) permit 'unjustifiable delay' before 'curative treatment' is started, and (c) choose as their initial consultant a physician whose culpability for delay is as great as that of a general-practitioner. Doctors, the BMJ 325 recently editorialized, investigate and treat themselves or their rela- tives inadequately by conventional medical establishment standards. The BMJ asked 326 the Director of Surgery at ST. Mary's Hospital, Lon- don, what he would do if he had cancer of the rectum. His submission is a revelation by itself: 'I am absolutely certain - and this I am sure will bring the wrath of most colorectal surgeons on my head, but no mat- ter - I would not have an abdominoperineal resection with a colos- tomy. However, managed, however much we delude ourselves, a permanent potentially incontinent abdominal anus is an affront diffi- cult to bear, so that I marvel that we and our patients have put up with it so long. It says much for the social indifference of the one and the social fortitude of the other.' 326 Two leading cancer pathologists con- fided to the authors that, should they develop a cancer, they will con- sult the authors and not any cancer specialists, but about this, "please do not tell the public."
A la Sontag, 288 doctors invent varied metaphors to demonize cancer and thus justify their 'brutal' therapeutic inflictions on their patients. How do we cure doctors of this dilemma? Erik Erikson 327 in Hippocrates Revisited offers some sound advice to doctors in the treatment of their patients: 'What is hateful to yourself, do not do to your fellow men.' It is time that doctors heeded this invocation in full, and in the context of cancer therapy paraprased it as: What is hurtful to ourselves, let us not do it to our fellow men called patients.
Just as 'diagnosis' is imperative, for a person who merits it (see earlier), 'treatment' is necessary for a patient dis-eased by cancer. Jory Graham 287 is quite right in that cancer is more curable than many other diseases. But the cure that Graham refers to has to be under- stood before it is advertised. 'In 32 years' experience in the USA, Canada, and Great Britain, I have never seen a patient with internal cancer or breast cancer cured in the sense the ordinary man under- stand the term cure - i.e. to take a disease process away and never have it come back.' 328 Let us accept that every cancer is curable , be- cause it is, always, careable . And this ability to be cared for includes palliation on the one hand, and life-respecting measures on the other. The venerated cancer text, titled Cancer Medicine 167 re- veals its true and glorious purpose when it tells at one place 329 that 'symptomatic treatment' of cancer constitutes the 'best clinical man- agement' and forms 'the backbone of any specific cancer therapy.' Palliation, thus, becomes the purpose of cancer therapy. And could one ever talk of radical palliation? It is a sign of coming change, how- ever begrudged, 330 that mutilative cancer therapy is getting replaced by conservative, organ/limb-saving 331 procedures. And this is but a mode of life-respecting. The recent Hospice Movement 332,333 in the West reflects the spreading acceptance of the fact that even a patient with terminal cancer needs, above everything, the dignity of being, both physical and mental.
The oceanic mass of 'facts' on cancer - the outcome of the devoted work of many scientists the world over for so many years - may appear forbiddingly large to permit a useful, practicable synthesis. The concepts and the facts presented in this book speak otherwise - it is possible to integrate the results of clinical and experimental research into a perspectival view appealing and comprehensible to the researchers, doctors, lay people, and above all, the cancer patients. Set below is the gist of the aforemade synthesis:
1. Cancer cannot be caused, cannot be prevented. About its affect- ing you, adopt therefore a que sera sera attitude.
2. Remember that cancer has been with mankind since ages and its occurrence is neither a freak of nor a punishment from Nature. Every cancer is a part of your own self. If you must not love it, you need not hate it either.
3. Each cancer, before it bothers you, or your doctor, has been with you for a long time. Early diagnosis/treatment for a cancer is a myth to be buried.
4. For the reasons cited above, it is not at all necessary for you to get yourself screened for cancer. Bother yourself about cancer when, and only when, it really bothers you.
5. Cancer does not always kill, nor does it always connote a short post-diagnosis or post-treatment life. Decide to live with your cancer until it chooses to die with you.
6. Appreciate that cancer need not necessarily disrupt either your profession or your joie de vivre.
7. Since there is nothing like a cure for cancer, insist on being treated symptom-far and no further. Any form of therapeutic radicalism is despicable overkill by medicine.
8. Must you be treated, seek surgery; should you be irradiated or given chemotherapy,insist on the minimal and be prepared for the cellular levy from head to foot that your body must pay.
9. You owe a duty to your body and soul in the form of a dignified death. Do not deny yourself the dignity of dying.
10. Cancer is a species, class, or ordinal character. You can neither inherit it, nor pass it on to your progeny.