A Short History of Medicine!
"I have a sore throat." 2000 BC : "Eat this root"
1200 AD : "That root is heathen, say this prayer."
1500 AD : "That prayer is superstition, drink this elixir."
1800 AD : "That elixir is snake oil, Take this pill."
1900 AD : "That pill is ineffective, Take this antibiotic."
2000 AD : "That antibiotic is artificial, why dont you eat this root."
- From A 21st Century Perspective
The first decade of the new millennium continues to reveal the Bourbonic nature of the Cancer Establishment. Bourbons learn noth- ing, forget nothing. Cancer specialists world over continue to be quite aggressive in their claims and media coverage. A brief survey of the cancer scene in particular and modern medicine in general is pre- sented below to buttress the main text. What is true for cancer is true for coronary artery disease (heart attack), stroke, high blood pres- sure, diabetes, arthritis and aging.
Perusal of media and medicalese reveals that both continue their cru- sade of grabbing headlines. The media-trivia, reportedly dependent on "scientific" studies, reflect the medical ploy of promise-to-prosper. The unceasing promises from the scientific-lobby keep on convincing donors and governments to dole out yet more funds. The labs, hospi- tals and doctors prosper and justify this prosperity by yet more papers and promises. All, except the cancer-patients themselves, are happy. The mood is upbeat, the truth missing. A brief survey of some head- lines is educative.
The Joy of Cancer, (Rupa, 2002 and 2005) by Anup Kumar, a nuclear physicist describes his own sojourn through diagnostic and therapeutic oncology, highlighting the travails about the monetary cost. Kumar is one of the lucky ones (see below, about luck in cancer) to survive, a phenomenon more common to the untreated than the treated. The Times of India, Nov. 2005, reports Nano plans for battle against can- cer, both for diagnosis and treatment. The Scientific American (July 2006) has a cover story posing a question - "DO STEM CELLS CAUSE CANCER?" and then goes on to epigraph the big article: "A dark side of stem cells - their potential to turn malignant - is at the root of a handful of cancers and may be the cause of many more." This formi- dable scare gets matched by many a sop. Time (Aug. 7, 2006) flashes a cover story on THE TRUTH ABOUT STEM CELLS and details on the governors and senators pouring a Niagara of dollars on stem cell- labs to conquer cancer, coronary and so on. WiCell - The Journal of Stem cell Discovery, (Spring 2007) gives a flashy account of this fledg- ling science to claim, on the cover, the plans of journeying "From the Laboratory to the Marketplace." Stem-cells may fail to provide the wanted cells, but seem sure to provide financial bonanza.
More from 2007. THE PHAROS (Autumn 2007) published by California's Alpha Omega Alpha Honor Medical Society, being "Wor- thy to Serve the Suffering," editorially generalizes that "Americans expect the most advanced and effective diagnosis and therapies for disease, no matter the cost" a trait partly derived from "our obsession with 'fighting disease'." In the same issue, there is the story of Abram, a successful lawyer 'who tried to cure his own cancer'. Abram got treated by James Holland, an oncologic luminary. "He (Abram) ap- provingly referred to the intense and strong-willed Holland as some- one who 'attacked my illness as it were a personal enemy, as if the mere existence of leukaemia were an affront to his power." The fore- going is a brilliant testimony to the megalomania oncologists often suffer from, the world over. Abram's story is reported to Lerner, a pro- fessor of Medicine at Columbia University, and is a part of his re- searched-book titled When Illness Goes Public: Celebrity Patients and How We Look at Medicine. Abram was treated, rather intensely, by a combination of immunotherapy, chemotherapy, and undaunted will. Lerner offers his observations on each of these, and his generaliza- tions are applicable to any other patient of any other cancer. "Indeed, while immunotherapy is still a focus of leukemic research, no ran- domized controlled trials have even shown that MER (Methanol Ex- tract Residue) or neuraminidase-treated leukemic cells prolong life." About chemotherapy given to Abram, one must read between the lines: "It is most likely that Abram's survival should be credited to the new 7+3 chemotherapy regimen that he received…. Of course, the chemotherapy does not alone explain Abram's case, as most patients treated for the disease still die. Why do some patients who have a given cancer and undergo a particular treatment survive, while others do not? According to growing evidence, specific cases of AML, like those of other cancers, are biologically different even though they carry the same name. Some are simply more treatable than others." Lerner resolves this dilemma by growing fatalistic: "This fact intro- duces another important element into Abram's story: luck. Whereas he was certainly unfortunate to get leukaemia, he was fortunate to get a treatable form of the disease." The foregoing takes you to oncoresearcher Fould's 1969 generalization that cancers are good, or bad, a retrospective judgment depending on how they behaved after treatment. This is in line with Kurtzke's generalization after a global study on stroke, namely, that survival depends not on who is treating or what the treatment, but who is being treated. Lerner, Foulds, and Kurtzke allow you to summarize that in cancer, coronary or stroke, treatment per se is irrelevant and what gets treated, now and again, is the dis-ease accompanying the diagnosis. The corollary is that, how- ever grave the diagnosis, treatment is avoidable in the absence of dis-ease. Lerner's comments on Abram's will-to-live are worthy of note, especially for the atheists. "But Abram's belief that he had willed his way to survival is more problematic. As noted above, existing research does not support the idea that cancer patients who try harder are more likely to live. In addition, such a construct potentially blames those patients who do not survive. One woman who wrote to Abram after the New York Times article made this point, reminding him that many courageous people with cancer nevertheless died from the dis- ease." Abram's story came from a top-notch USA society, and de- served wider description. A few more bits from 2007 follow.
A 27 Oct 2007 The Times of India headline informs of a 'smart' bra that will send audio-visual signals in detecting an early cancer, con- cluding on a caveat: "The life-saving undergarment will be manufac- tured within the next two years." The 22 nd Oct headline is on India's 500-crore cancer-drug market coming of age to compete with global sales, a marketing fact highlighted by Jacky Law in her book The Big Pharma (Constable, London, 2006). It is a classical case of dollars from drugs that really never were. Tehelka of Dec 15, relates Guha Ray's account of his mother's cancer, the article being titled: 'I RE- CALL WHAT MY UNCLE SAID - CANCER, NO ANSWER.' The Times of India of 27 th Dec, reports on 'A nuclear tool to fight cancer'. The details provide an insight into USA's determination, no matter what the cost and what and who the enemy. "But a 222-ton accelerator - and a building the size of a football field with walls up to 18-feet thick in which to house it - can cost more than $100 million. That makes a proton centre, in the words of one equipment vendor: 'the world's most expensive and complex medical device'. Some experts say the push reflects the best and the worst of the nation's market-based health care system, which tends to pursue the latest, most expensive treat- ments - without much evidence of improved health - even as souring costs add to the nation's economic burden." Significantly, 2007 ends with a sort of bang. Watson, the hero of The Double Helix , who in 1975, summed up cancerology as scientifically bankrupt, therapeuti- cally ineffective, and wasteful , champions each one of us having a CD of one's own DNA. He got it made for himself at a modest cost of one million dollars, but he envisages a time when, a decade from now, it will be $1000 per genome. Given this you can, from almost very beginning of your life, start predicting (may be apprehending) Alzheimer's, so as to start working against it. Watson's advice is a classical play of ruining one's journey of life, for, unpredictably, end- ing on a desired state of dis-easing.
While some elitist eyebrows may be raised for quoting science from lay media (who in any case got it from learned medical men), it would be appropriate to cite here a very personal account of a British lady treated by modern cancerology. "To My Oncologist - an Open Letter from a patient at the End of Follow-up," in Clinical Oncology , 19: 746- 747, 2007, under the aegis pf the Royal College of Radiologists, UK. The patient merits being quoted in extenso , as follows.
This letter has been reproduced by members of the Macmillan Late Effects Working Group to stimulate discussion and debate among oncologists.
Since 2005, a group of patients and carers, representing those affected by significant complications of cancer treatment, has been working with the Macmillans. They include representatives of RAGE (Radiation Action Group Exposure), but the wide collective experi- ence of the group extends across different cancer types and all age groups. Their aim is to increase awareness and recognition of late effects, and to improve the information and services that affected individuals receive.
Everybody says how well I look, and I guess I am cured now. So, as your registrar says, I can put it all behind me. Funny, it feels a bit like when I was first diagnosed with endometrial cancer. First the hysterectomy, then the radiotherapy with internal treatments. 'Just get through the tiredness and diarrhoea, it's all to be expected, then everything will be normal again.' But, it's never been the same, never my 'normal' as I once was.
At first, I would ask how long I would be a bit loose, or having to rush to the loo. I didn't like to tell you I was having accidents, how embar- rassing. You did ask me once if we were managing intercourse. I know I said yes, but I couldn't tell you how sore and uncomfortable it was. My husband gave up after a while, he could see he was hurting me. I used the dilator just as the nurse instructed, but it has never been the same. I wanted to know if everyone was like me, but I never had the courage to ask.
There's another thing, my bladder. In the first year I kept getting cystitis. After this, I couldn't last for more than an hour. Everything now needs careful planning. I kept going back to my GP who gave me antibiotics, but they made little difference. A couple of years later, I had some bleeding from the back passage - that really alarmed. You sent me to the specialist who carried out a colonoscopy. It was very uncomfortable, but at least he had an answer. He told me the radiotherapy had damaged the bowel and that surgery might be needed if the bleeding didn't stop. Fortunately, it did. I eventually understood that this was the problem with my bladder, too. It had just shrunk.
Perhaps you did tell me at the beginning, before the treatment. I don't think I took it in, and when I did learn about radiotherapy dam- age, it was hard to find answers. There is so much I still don't know. Will it get worse? What will happen to me?
I think I was quite angry with you at this time, but I eventually realised that my problems weren't caused by bad treatment, they just hap- pen to some people. I just didn't understand, but that made it harder to keep bringing the subject up when you saw me in clinic. 'How was I?' you asked. On a good day uncomfortable, using pads, and plan- ning carefully every time I went out of the house. On a bad day, I'd rather not eat than embarrass myself in front of family and friends and I sleep in a separate room now.
My GP says he has not seen anyone like me before. For a long time, he said he didn't know what was going on. He admits he has little experience in looking after people with different types of cancer and especially in dealing with the after-effects. I often have thought that it would have made a difference to talk to other people who had similar experiences. That's been the worst thing - at times I have felt that I was making a fuss. Eventually, finding out that all this was late effects on my bowel and bladder almost came as a relief. At least there was an explanation.
I don't mean to grumble. I just want specialists like yourself to realise that it is not just the big problems like bleeding, it is all the little things put together that wear us down. We don't expect you to have the answers - by now I realise there aren't easy ones - but it helps to be able to talk about them without embarrassment. If you can put in our notes that there is no sign of cancer, isn't it important to write down what else we are living with, if only so that other doctors and nurses will understand too and we can judge if things are changing or get- ting worse.
With hindsight, I think I needed to be more prepared for this at the very beginning - that life would be different rather than expecting everything to be the same. More information. This would have helped, as well as getting information when problems begin. When they do happen, it is so important that our symptoms are recognised and acknowledged as part of the treatment effects. At least that gives them a label and an explanation. Even so, it is hard to qualify for benefits, and GPs and other people simply don't understand what I am talking about.
It must be noted that the above sad tale has the backing of UK institu- tions of impeccable authority and scientificness. And, reading between the lines, you realize that the patient swapped what was occasionally disturbing uterine bleeding, with a state of perpetual ill-health, ruined sex-life and social life. Earlier, we have cited the case of 3 women. Mrs. D, sister to one of us, had a large bulky endometrial carcinoma that allowed after diagnosis, a full 7 years of normal life, save occa- sional bleeding. Two other women had advanced carcinoma cervix, spread to the sides of the uterus. One lived normal and well for nearly 5 years, the other for 19 months, the sole treatment being a few vagi- nal douches to manage the discharge. Allopathy has been officially defined as the art of curing one disease by causing another. In the letter above, oncology "cured" one by causing many a dis-ease. Prof. B.M. Hegde, physician-cardiologist-writer-vice chancellor has posed in Bhavan's Journal, Jan 2007, a question "Is Cancer a Disease? which is but exact equivalent of the German translation of our book titled Ist krebs eine krankheit? The corollaries are that cancer is evolutionarily and ontogenically integral to humankind, that for long after its incep- tion it is compassionately and discreetly silent, that as and when it dis-eases, all that you can and should do is to ease the dis-ease, and that while doing so you should see that your easing does not turn into an adventure of making your treatment costlier than the patient's original dis-ease.
2008 is full of breakthroughs. A research team at Utah, USA ( Hindustan Times Jan 3) have traced colonic cancer in the whole of USA to a couple who migrated from England to America in 1630. "Colon cancer traced back to 1630" so the headline proclaims and then goes on to explain the countrywide "hereditary" transmission of a gene and its mutation in the face of the fact that as terms and concepts gene, mutation , and hereditary are all begging for a logicizable status. The thrust of the whole learned piece, colourfully showing the (long- out-dated) tumour stages, is a marketing gimmick to sell yet more check-ups, colonoscopies, biopsies, and surgeries. Feb 4 The Times of India announces the nailing of a "gene that tackles tumours." The launching text is bitter-sweet: "Paris: Scientists have identified a gene that helps protect mice against intestinal tumours, although it may also play a role in spreading cancer."
Jan 21, The Times of India arrives with a new Merkel Cell Virus (MCV) which is the first polyoma virus to be strongly associated with a par- ticular type of human tumour. In tandem is an announcement ( The Times of India Feb 3) that "Oral sex can cause cancer in man." The box assertively declares: "The sexually transmitted virus, HPV, now causes as many cancers of the upper throat as tobacco and alcohol, probably due to both increase in oral sex and the decline in smoking." This study published in Clinical Oncology suggests that the Merck vaccine, "currently given only to girls and young women" can now directly benefit men busy with oral or anal sex. Surely, the vaccine is busy doubtfully preventing cervical, oral, anal cancers to positively promote Merck profits. The readers need to note the poorly- recognized open secret that Robert Gallo, of the AIDS virus-ill-fame, was working on HTLV - Human T-Lymphoma Virus, wherein persis- tent failure led him to suddenly announce the existence of, as yet unproven and unisolated, HIV - also called AIDS virus. Viral oncology had died long ago, but laboratories have resurrected it profitably. Next to the viral breakthrough, is a "New treatment for brain tumours" de- tailing the combination of radiation seeds and chemotherapy wafers after surgery as assuring longer survival in Glioblastoma Multiforme (GBM). Oncologists continue to believe in Borgia's law: Two poisons are better than one.
An avalanche of scary-information is let loose by media ( Bombay Mir- ror Jan 19) with a grief-stricken young woman facing the intimidating question: "HAVE YOU TESTED 'TRIPLE NEGATIVE'?" The epigraph to the article reads: "Most people haven't even heard of triple negative breast cancer. What's more scary, it's harder to treat and more common in young women." The text reeks with media- malignancy passed on to the public as some latest knowledge.
Ecclesiastes stands proved right: He that increaseth knowledge, increaseth sorrow , for as Lord Tennyson put it, Knowledge comes, but wisdom lingers. One of us has had a chance to attend a 'Grand- round' in a California hospital, which was a slide-show laced with break- fast. At the end, a person on the next-chair asked how it was. "Good". "You see, we have some problem here. One moment I think A causes B, and press a button, and I get 100,000 references in its favour. A little later, I change my mind to say A does NOT cause B. And I get 100,000 references. You see we in the west are well-informed, a little too much, but we haven't grown wise." The magnificent tomes called
Controversies in Psychiatry/Medicine/ so on truly speak volumes about modern medicine's oceanic knowledge sans an island of wisdom.
February 13, 2008 brought flashes from Health Screen - A magazine for pre-patient care (Vol. 4, No. 38, Feb 2008). The intellectually-un- comfortable term pre-patient should tell you that it is a journalistic mouthpiece of " Thyrocare - world's largest thyroid testing laboratory." The first item is on Siemens' Mammomat Inspiration - "latest innova- tion in digital mammography." While mammography has yet to come out with a clean chit of beneficence, the announcement by Jochen Dick, the chief of Siemens Medical Solutions bristles with pecuniary illogic: "In an environment with large screening volumes such as mam- mography, many patients have to be examined, and some of them are very nervous about the procedure, that's why the entire proce- dure has to be as fast and as comfortable as possible for the patient while speed, efficiency, and accuracy are the deciding factors for the hospital. For this reason, every work step, starting with the examina- tion and ending in data distribution has to be optimized so that more patients can be examined and diagnosed in a far shorter time than in the past. Additionally many functions and technical features provide for low radiation dose." More mammography, more surgeries/chemo- therapy/radiation/hormones and misery.
The next item in the above is on the Nobel award, for 2007, to Capecchi, Smithies and Evans for their discoveries "that paved the way for an inestimably powerful gene technology referred to as gene-targeting in mice, or to use the more common dialect, gene knockout mice," lead- ing to breakthroughs in ailments of aging, diabetes, and of course, can- cer. While James Watson was a bit conservative in promising a utopia, the Health Screen goes too generous: "The avalanche of genome data is growing day-by-day encompassing studies in trascriptomics, proteomics, structural genomics, knockout studies and comparative genomics. The knowledge of DNA sequence may find relevance in al- most any biological subjects and the application of genome sequence information to health benefits could revolutionize disease prevention measures, early disease interventions, and make the possibility of per- sonalized therapies routine." Health-Heaven just round the corner!
The Times of India , March 14, 2008 has a headline, from where else but USA. "US scientists discover 'master' breast cancer gene." The report details geneticists having identified a super gene which causes breast cancer to metastasize. The master regulator SATB1 gene alters the behaviour of at least 1000 other gene within tumour cells, says the study published in the British journal Nature. SATB1, when overactivated, makes cancer cells proliferate, and when neutralized, the gene forces the insane cells into sanity. The report offers the car- rot of cure: "The findings could not only pave the way to diagnostic tools that show likelihood of the disease spreading, but to drugs that could prevent or treat metastasis in breast cancer as well." Hope, you see, springs eternal in the human breast, especially if the breast belongs to a researching geneticist in the USA.
Breakthrough headlines over, we may descend to some ground- realities. Despite seeming Himalayan advances, modern medicine is essentially ignorant about the two basic elements that form the human body - namely, cell and collagen fiber. These two elements govern all the maladies we are prone to. Regardless, modern medi- cine continues to "attack" with results no better than USA pounding Afghanistan or Iraq. The net outcome is iatrogeny - doctor-induced diseases. It has been predicted that by 2025 AD, 80% of human suffering will be attributable to doctors themselves.
This is best illustrated by USA, the world-leader for better or worse. As summed up in Time June 31, 2006, medical errors remain one of the leading causes of death and injury. The Institute of Medicine Report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors. Using the lower estimates, medical errors are the eighth leading cause of death in the USA - higher than vehicular accidents, breast cancer, or AIDS. These figures more than justify the warning that Edgar Berman, an Ameri- can surgeon, put on the cover of his book, titled The Solid Gold Stetho- scope - "Your Doctor May Be Hazardous to Your Health."
If the above is true for ever-vigilant and always-litigant USA, what must be the state of doctor-caused disease/death in India or Africa?
No wonder that the media, traditionally given to praising the medical world, have started giving cover stories on the perils medical practice poses. The October 2004 issue of the famed Economist from UK fea- tured a cover story on "Beating Cancer" wherein the launching line is: "There never will be a cure for cancer." This pessimism of a presti- gious British periodical finds a strong echo in Nature (London) August 2007, declaring Cancer and aging, as two sides of the same coin, and hence integral to human growing. The May 2006 issue of Business Week (USA) has the cover-title: "Medical Guesswork - from heart surgery to prostate care, the medical industry knows little about which treatments really work." The Reader's Digest (USA) (August 2006) went a shade further, declaring on its cover: "How Doctors Gamble with your Life - Seven ways to protect yourself." The Reader's Digest cover shows 2 dice as the main instruments that doctors employ to guess what they should do, when, and how.
So, it is high time we all, the lay and the learned, appreciate and adhere to the true meaning of some medical words. Doctor (from Skt. - digga = disha, diggdarshak, director, doctor) is one whose chief role is not to give medicines or do surgeries, but to give directions along which to conduct one's life in health and sickness. The much-used phrase modern medicine is a tautology. Both these words are trace- able to Skt. matra and L. modus meaning measure. Modern Medicine is something that you do as a measured step and dosage, after taking all factors into account. So modern does NOT mean the latest/im- ported/sophisticated/ expensive, but a way of taking even the latest failure of medical practice into account before succumbing to any treat- ment. The much-celebrated word investigation is rooted in vestige or a trace. However costly it may be, any "report" tells very little about any particular illness. Like our political bigwigs, an investigation can as much mislead you as it may lead you. So, beware, for in the best- intended "fight" between a doctor and your disease, the real battle- field is you, your body, your mind, your finance.
It may not be realized that a 5-star check up-clinic is a magical place where a person walks in, and a patient walks out. The check-up-clinic's motto as outlined by the Wall Street Journal on July 26, 2006 - You are sick, We are quick - is as seductive as a TV ad, and far more dangerous.
It cost USA billions of dollars to complete the Human Genome Project (HuGo). Blaire and Clinton eulogized the report as the language of God and the code of life. Soon, however, its limitations were realized so that it has been consigned to the dumps. The place of genetics has been usurped by proteomics. Yet this summary failure of genetics has not deterred the cancerologists from promising a molecular classifi- cation of cancers: "Cancer classification has been based primarily on morphological appearances, which have severe limitations." This learned judgment by R.D. Lele in Journal of Physicians of India in April 2003, throws the best microscope into the sea, and poses a serious new challenge: The new classification is based on global gene expression using DNA microarrays. All this, mind you, when science is still struggling with what really gene is, and how to define it.
As stated by Dr. Lele, "The National Cancer Institute and Food and Drug Administration in USA have since July 2001 joined in a separate effort to focus on using proteomics to develop more targeted treat- ment and more reliable diagnosis of cancer." No body could have said mea culpa, mea culpa, more loudly. The damning words declare that hitherto cancer-establishment has been wrong in diagnosis, as also in dishing out such breakthrough as Herceptin , and Gleevec (The Wall Street Journal, July 24, 2006) . Why not, for once, should doctors declare that cancer never has had, not can have, any drug, for the simple reason that cancer cells refuse to accept that they are in any way abnormal to the human body.
What would you feel when a 11-year old girl is made to pose ( Time, June 19, 2006)for the sale of a vaccine designed to prevent cancer of the cervix? The FDA, USA have approved Gardasil, an antiviral vac- cine, costing $360 for 3 shots. The assumption is that cervical cancer - 233,000 deaths per year worldwide - is caused by HPV or Human Papilloma Virus. So give the vaccine, as a routine, to girls between 9 and 11 before they begin to be sexually active. "The Gates Foundation announced that it will spend $28 million over the next five years to determine whether a cervical cancer vaccine can be made more widely available." Gardasil (MSD) and Cervarix (GSK) are now aggressively promoted in India, at considerable expense to the recipient.
Sweden ( Times of India Nov. 25, 2008) has taken lead in "preventing cervical cancer" in 100 women every year, by offering from Jan. 1, 2010 free veaccine "to all primary school girls as a part of the country's free veccination programme" at a modest cost of $ 48.3 million a year. The cost, per cancer prevented will be, about 0.5 million dollars.
While science is greatly uncertain whether HPV causes cervical cancer or genital warts, and whether antiviral vaccine could really work, the Gates Foundation and the Wall Street Journal (July 21, 2006) have decided that everything be done to make the vaccine available world- wide. Is this vaccine a way of reestablishing the long-defunct theory of the viral origin of cancer? It is interesting that Dr. Kirtee Shah at the Johns Hopkins has done "crucial" work to link cervical cancer to HPV.
While it is accepted that science has very poor idea of what a cell really is, it is now widely claiming stem cells as a panacea for a num- ber of medical problems, cancer included. It is not clear how stem cells, basically designed to proliferate, will help protect/cure/modify cancer that is itself a disease of proliferation. India has been quick to board the stem-cell-bandwagon, regardless of the cost and the con- fusion involved: Singapore has the (2 million sq. ft.) stem-cell-centre, called the Biopolis that is supposed to have seduced the best brains from the USA and the UK.
From the enormous data available, it is not difficult to generalize that stem-cell strategy is a stunt designed to keep the medical research alive, and human hopes kicking. The Time (Aug 1 2006) has the cover titled: "The Truth about Stem Cells - The Hope, The Hype and what it means for You." The article begins with caution that speaks for itself: "The debate is so politically loaded that it's tough to tell who's being straight about the real areas of progress."
The witch-hunting of tobacco continues. The August 2006 issue of Journal of Association of Physicians of India (JAPI) is devoted to creating a "Tobacco Free India." The editorial declares that "Cigarette smoking is responsible for more than 400,000 deaths each year, or one in every five deaths." Surely, Lady Nicotine was never more condemned!
Our tobacco-phobia needs to be intellectually treated. If the doctors have been loftily wrong in the diagnosis and treatment of cancer (and all other diseases allegedly caused by tobacco), is it likely that they could be as grossly wrong in their statistical claims? How about the statistically established fact that the tobacco habit prevents Parkin- sonism and Alzheimer's disease? The current epidemic of both these diseases could be the unavailability of a natural product called tobacco. Time alone will tell, but it suffices to say that all pronounce- ments so far have had more rhetoric than reason.
The continuing failure of cancer research, stemming from the verifi- able fact that "Cancer is Unresearchable" (Ch. 10 of this book), has given a great boost to the phenomena of Foundations. A tycoon or his/her near-one gets a particular cancer to die therefrom, and a Foun- dation-for-that-cancer springs up. "Early Detection: Ex-Executive Backs Big Push to Get A Jump on Cancer" so goes the headline on the front page of the Wall Street Journal of July 12, 2006: "Multimillionaire Mr. Listwin's mother died of ovarian cancer. So there is now the Canary Foundation to detect cancer in its earliest stages by locating "the fingerprints of tumours." Mr. Listwin is in good company. "Following his diagnosis with prostate cancer in 1993, the former financier and convicted security-law violator Michael Milkan estab- lished the Prostate Cancer Foundation to support research into the disease. More recently, he founded Fastercures, a Washington- based action-tank that attempts to accelerate the translation of basic scientific discoveries into medical treatments."
If one were to read between the lines, be it cancer, or stem-cells, the continuing emphasis on million/billions of dollars smacks of "an individual style attack" on cancer. The gullible public and the press are made to feel that all that is lacking is just enough dollars and enough push.
Robert Ardrey, an eminent thinker/writer/anthropologist left behind a good truth in 4 words: Apples still fall down. All our knowledge on gravi- tation, from the time Newton gave the concept, has not helped us alter gravitation; nor make the apples fall up. The moral of the story is that an oceanic mass of information on a cancer or a cancer cell may still be obstinately accompanied by your total inability to dictate orders to a single cell. This is the essence of the new science of epistemology or gnosology (from Skt. gnan = knowledge). Epistemology evaluates a knowledge-scene and tells you what you can do, and what you just can not. From Sushruta and Charaka, to today - 2500 years - mankind has striven to challenge the naturalness of cancer, with results that are both disturbing and destroying. The saving grace is that the less you do against cancer, the more it obliges you to live longer and better with it. Cancer is kind. The kindness begs for recognition.
It will be clear to the readers of this book and the new update that the authors have striven to adopt the PRIDE approach as proposed by them at the Leadership Conference on Best Practice, Health Care in India, held at New Delhi on November 19-20, 2005. PRIDE as an acronym connotes - Public/Patient Rationally Informed, Doctors/ Donors Enlightened. Public/patients should not over-expect. Doctors/ Donors need not over-promise, nor over-perform. PRIDE thus be- comes a symphony of shared knowledge and ignorance. Bill Gates and the like may be told that cancer research is a bottomless pit, a black-hole that sucks everything and gives back nothing. Clyde Dawe of National Cancer Institute, USA generalized that trillions of animals sacrificed on the altar of cancer research have not provided any clue that science did not already had had before the experiments began. If this means the cancer institutes and laboratories could better close down, so be it. The SPCA will be happy. And so would be Albert Schweitzer and his motto Reverentio Vitae , or Reverence for life.
As this text goes to the press, a flyer has arrived from a prestigious new cancer hospital. From Pune, India. It has the typical overpromisism and razzmatazz of modern medicine - rich in expectant appeal, but thoroughly impotent in reality. It is a classical universal ploy of keep- ing the flame of a defunct science alive. Any 5-star research estab- lishment - in physics, genetics medicine - must periodically produce "results" to satisfy the public and the funding agencies. They get satisfied, and the cycle of survival continues. The only casualties are truth and candor. But then that is pure science and who worries about that facet of Goddess Sarswati?
Our attempt is not to find who is at fault, or what is wrong but to stress what is self-evidently right. Cancer is easy to understand. The simple truth that binds a cancer patient with his/her doctor is that the latter is endowed with the ability to ease, if and when there is dis-ease. Can- cer yes, but no dis-ease, then let cancer be. If dis-ease, seek ease, dis-ease-far and no further. Cancer by itself can NEVER be treated. What doctors treat is not cancer, but a symptom or sign. But that also is a great blessing from a noble profession.
The foregoing citations are a few drops from oceanic oncology that expands every minute. It is a game of scientific research, one- upmanship, bio-industry-promotion, and of course, Nobelitis: "To a great many people, medically trained scientists as well as layman, the pot of gold at the end of the rainbow of medical research is the discovery of the cause and cure of cancer." We first published Myths and Realities of the Cause and Cure of Cancer in 1979; the text is unaltered even by a punctuation mark as of today. How come the oncologic juggernaut continues to run amuck!
Does it come out of a current world-view that nothing is unsolvable by science if there are enough money, machines and men? Scientists have chosen to connive at the fact that, science as a word is from Latin scientia , i.e. to know, having no relationship with doing, which is technique from Skt. takshta meaning skill. That is why when we say God is omniscient, we imply the Lord's all knowingness, and omnipo- tent connoting all-doingness. The moot question is: Is there any sci- ence of cancer? Bier's lofty, 60 years old, generalization that "All we know about cancer can be written on the back of a calling (visiting) card," the text being WE KNOW NOTHING is robustly viable today. And if that is so, let it be noted as of 2009, that all cancerlolgy is all technique sans any science. Burnet, the hard-hitting Nobelist has summed up succinctly:
It is a current article of faith that if America can put a man on the Moon, America can discover the cause of cancer. In Arizona there is, we are told, a cemetery where people who have died of cancer are preserved by being frozen in liquid nitrogen 'in the sure and cer- tain hope' of revival and cure by the medical scientists of the twenty- first or twenty-second century. I have been and remain a sceptic and was castigated in public by a local president of the British Medical Association for saying about ten years ago that I could see no hope for any revolutionary improvement in the cure of cancer. It is still an unpopular attitude. As long as money for research must be sought from men without sophisticated understanding of biology we can be certain that every geneticist and molecular biologist will be care- ful to add to his exposition of what he is doing, the safely irrefutable statement that it may well have importance for the understanding of cancer!
- Sir Macfarlane Burnet
Genes, Dreams and Realities
But, the current craze of nano-/pico-/femto technology has promised breakthroughs in all medical fields through the miracles of molecular biology. Some have gone a step further to hold discussions on
Submolecular Biology of Cancer. Be as it may, Burnet needs to be read in 2009 for the candour he exhibited in 1971.
I have more than once expressed the opinion that so far there has been no human benefit whatever from all that has been learnt of molecular biology. I doubt if any other biological scientist has been quite so blunt in public but a few eminent biochemists have agreed with me in private.
Any of the other aspects of cancer research that I have mentioned could provide opportunities for expansion and interpretation but I think it would fit best with the general approach of this book to look rather critically at that perennially repeated justification for work in molecular biology - that all competently done research in funda- mental aspects of biology will help toward discovering the cause and cure of cancer. I believe that most scientists who make this claim, usually to justify public support for their own work, feel that they are virtually compelled by social forces to tell this white lie with as much apparent conviction as they can muster. They know that their own work is rated as good by their peers, who are concerned not at all with its bearing on cancer but deeply with its originality, its integrity of approach and interpretation, the elegance of the methods used, and the implications it will have for the interpretation of other biologi- cal phenomena. They are rightly proud of their achievement and equally rightly feel that they have won the right to go on with their researches. But their money comes from politicians, bankers, foun- dations who are not capable of recognizing the nature of the scientist's attitude to science and who still feel, as I felt myself thirty years ago, that medical research is concerned only in preventing or curing human disease. So our scientists say what is expected of them, their grants are renewed and both sides are uneasily aware that it has all been basically dishonest piece of play-acting - but then most public functions are.
- Sir Macfarlane Burnet
Genes, Dreams and Realities
The last line in the above portrays a global situation that is MAD - Mutually Assured Delusion, the rulers, senators, legislators, politicians, and the big-purses ready to dole out yet more funds without under- standing the trans-science nature of issues involved. The research- ers on the other hand survive, nay thrive, by asking more and more funds without wanting to own up and explain the limitations of the science they are ostensibly pursuing. Funds flow in to fuel research that must be published to justify yet more funds.
Burnet's hard-hitting candor allows molecular biology to be reread as mole-ocular/mole-eyed/blind biology, a current craze very long on promises and, as yet, not even short on performance.
If the molecular approach in biology has yielded a cipher, may be molecules in our food - micronutrients - can help. Towards this end, Matthias Rath, of the Dr. Rath Research Institute, California, sees Conventional Cancer Therapy as "a Dead-end Street" full of chemo- poisoning. He gives a picture of the hairless King Hussein of Jordan and provides the course of his illness: "It is not just ordinary people who end up in the dead-end street of conventional medicine, as we see in the example of King Hussein of Jordan. Convinced that he was receiving an excellent treatment for his leukemia (blood cancer), King Hussein moved to the Mayo Clinic in Rochester, MI. We all know the result: the chemotherapy destroyed the king's bone marrow. In order to replace it, a bone marrow transplant was required, which King Hussein did not survive. The chemotherapy killed the king faster than the actual disease would have."
Dr. M Rath promises a micronutrient-panacea pregnant with "The End of Common Diseases" and a prophesy that The Victory Over Cancer Is at Hand. Rath's mediutopia as detailed in publications of 2005 includes elimination of immunodeficiencies, AIDS, heart attack, stroke, and of course, cancer. Rath's efforts and publications date back to early 1990's, and the world must wait for the breakthroughs he has envisioned.
A heady mix of medicalese, politicalese and journalese is exemplified by a recent cover story in Time (Oct 15, 2007). A pretty woman adorns the entire cover page, with much of the world map painted on the front of her torso, her right hand cupping the left breast, the title being
Why Breast Cancer Is Spreading Around The World. From the edito- rial through the whole story, aggressive, accusative generalizations veer the reader into championing "the US-based Susan G. Komen for the Cure , an advocacy group with 125 affiliates around the world." While the story bemoans the poverty of the Third World as one major handicap against tackling breast cancer, it shamelessly promotes popu- lation explosion, and yet more poverty, by generalizing: "Research shows that women who give birth to fewer than two children have a high risk of developing breast cancer than woman who have larger broods. Part of the reason is probably that pregnancy and nursing provide the body with a sort of estrogen holiday, as the menstrual cycle is shut down for at least nine months and often a lot longer." Moral is, Stay Perpetually Pregnant to keep breast cancer at bay.
At the end of the whole story, you get reminded of Sir Hadley Atkin's brilliant despair that the science of breast cancer is now so advanced that no one knows how to prevent it, or, treat it. And what is true of breast cancer is true of cancers at all other sites. This cultivated global democracy of delusions allows anybody and everybody to prevent/investigate/treat the way it pleases a fancy, even if, in the bargain the patient gets destroyed. It is an axiom in the line of Albert Camus: Nobody in the world of oncology is wrong because nobody is right.
The utter phoneyness of modern oncology as also the TRUTH about cancer between the lines, is revealed by fresh-from-the-frying pan
Current Medical Diagnosis and Treatment 2008, a medical bible read and respected by medical world over for the past 47 years.
The single most important risk factor for developing cancer is age. About 76% of cancers are diagnosed in persons aged 75 years or older.
An additional cause of cancer is chemotherapy or radiation therapy for prior malignancy. More aggressive chemotherapy and radiation regimes - and especially those combining two treatment modalities
- have been associated with increased rates of both secondary leu- kemias and solid tumours. The latency period may be short (2-5 years for leukaemia) or very long (10 - 20 years for solid tumours), but the prognosis is uniformly poor.
- Hope Rugo
Current Medical Diagnosis and Treatment 2008
The above tells the layest of lay that cancer is a part of aging, a part of one's course , not in need of a cause that never existed. The other glaring revelation of the above is that all chemotherapy is basically cancerogenic, or more truly, an agent that accelerates all modes of aging, including cancer. Sadly but significantly, the truths gleaned in 2009 will not alter by 3009, for cancer is a biological issue, well be- yond the nose of medical men, who are supremely placed to ease, whatever, wherever the dis-ease thereof. What is cancer, we cannot treat. Whatever we treat is not cancer.
We are, in the concluding part of this neomillennial update, tempted to introduce a new science called CommonSensology, a mosaic of basic understanding available to any lay or learned and guiding in what to expect, and what not to, for all times to come. The sole prin- ciple of commonsensology is to realize, and declare, the Himalayan limitations of the might of modernest medicine, may be in the richest country, with latest gadgetry, and all superqualified medicos.
I met a traveller from an antique land
Who said: "Two vast and trunkless legs of stone
Stand in the desert. Near them, on the sand,
Half sunk, a shattered visage lies, whose frown,
And wrinkled lip and sneer of cold command,
Tell that its sculptor well those passions read,
Which yet survive, stamp on these lifeless things,
The hand that mockt them and the heart that fed:
And on the pedestal these words appear:
'My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!'
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.
Percy Bysshe Shelley (1817)
Shelley's poetic summing up of the fate of mighty kings makes you recall a small event that came to pass on the seashore at, Southampton, England, a little over 1000 years ago. King Canute (Cnut) ordered the oceanic wave not to advance towards him. Yet, "When it advanced and wetted him, he said to his courtiers that they called him king, but that he could not stay by his commandment so much as this small portion of water." Time and tide wait for no man nor monarch, be it the time without, or more so, within.
Taking a leadline from Shelley, we can travel inwards into a universe called the human body. Let our journey be summed up in a few banal words:
I met a saint from every land
Met prince, rich and pauper
And one and all did acclaim
We control all, but never ourselves.
Our sneeze, snore, yawn, burp,
Vomit, Pee, Shit and Fart
Are kingdoms we never reign
And there lies the moral dart.
We inspire to expire.
And cease to expire,
Once we cease to inspire.
Death's end to dying.
We need to appreciate that a single human body is a cytodemocracy of astronomical numbers, 100 trillion human cells covered by 1000 trillion microbial cells, all living in peace and harmony, from womb to tomb, often over a hundred years without ever needing a medico around. It may surprise us that, after nearly 2 centuries of research on the healing of a wound - ranging from a shaving-scratch to multisys- tem trauma following a car crash - modern medicine has understood next to nothing of this highly computerized orchestration of cells, fi- bres, and blood vessels. At the Lister Symposium on Wound Healing, circa 1970, at Glasgow, chairman Bullough summarized the whole meet on 4 counts: (1) Nature attained its zenith of perfection in wound- healing long ago. (2) We know nothing about it. (3) We can do nothing to accelerate it. (4) Much of what we do, decelerates it. If Wound- Healing has been our Waterloo of medical insights, what to talk of the more complex issue of canceration!
A "normal" cell in your body, before it shifts to the pre-programmed cancerhood, converses with all cancers of the total human past, present, and future to see to it that it spawns a unique cancer, which talks to your own herd to decide at which age to occur, how fast to grow, whether to trouble you at all through life, when exactly to cause trouble, and so on. Your cancer cells enjoy the same genotype as all other cells, multiply never faster than your gut/bone marrow/hair fol- licle cells, and refuse to be classified as abnormal even after a battery of 400 comparative tests. Your cancer is a cosmic event, fashioned by forces beyond the constraints of space-time, and has an antecedence over all your so-called normal cells. As a cosmic event, it is beyond any cause. If it is to occur, it will. If not, nothing can cause it. Your clinician, no matter how well-trained and well-armed has a reach that is too local to affect the cancer's course. The fault is not of the clinician's incompetence. It is rooted in all his limitations.
The above, ordinary and understandable but undeniable facts explain why a very tiny drop of oceanic water, forming your normal or cancer cell, is unable to obey the clinician's demands much as the seawater at Southampton could not care for the order issued by King Canute. Your cancer cell, like any of your 100 trillion cells, is, like God, too subtle to be subservient to you or your science. Einstein loftily synthe- sized Nature's brighter as well as the inevitable darker side by perceiving it as a game. So he assured us: "Subtle is the Lord, but malicious He is not." We can use the same words for an amazing, interesting, universal, impartial, precise, perplexing cytologic phenom- enon called CANCER.
The ceaseless search of all sciences is a sense of certainty, a sense of precision, and direction. Given the vast array of tests and tech- niques, that keep on increasing their numbers and sophistication every other day, a cancerologist and his patient are justified in expecting a predictable outcome from this interaction. This has failed to happen so far. In cardiology or cancerology, every individual doctor-patient-interaction is blighted by uncertainty. So the doctor resorts to what is called Controlled Trial, wherein he treats a bulk of patients to arrive at some certainty, but, at a group level. Encouraged by this, he then foists the procedure/treatment on an individual patient, as blighted by uncertainty as before. The doctors, conferences, journals and media brag about the certainty they arrived at the group level. The misery of an individual patient gets drowned in the din and noise.
The whole scenario, world over, in all the scientifically-facaded, therapeutic Randomized Controlled Trials (RCTs), is evidence-based at the group/bulk level, and inevitably evidence-biased in the treatment of an individual. The fresh-from-the-frying-pan report ( The Times of India, Mumbai, March 17, 2009) on the pharmaceutical giant Pfizer, thriving for years on COX 2, eulogized in 21 "peer-reviewed" (but fabricated) papers based on RCTs puts into spotlight all the RCTs in all the disciplines of medicine. There is no RCT which does not need a pinch of salt.
Why such a mess after thousands upon thousands of scientifically impeccable trials? The explanation is simple, provided we replace our unending hubris by humility. Take the simple exercise of Squaring a Circle , that is, "To attempt an impossibility". Why can't our great 3 rd millennial science square a circle? "The allusion is to the impossibility of exactly determining the precise ratio, pie ( p ) between the diameter and the circumference of a circle, and thus (the impossibility) of constructing a circle of the same area as a given square. Approxi- mately, pie ( p ) is 3.142857142857142857…….." ad infinitum et nauseaum. If you the Homo modernus et scienticus is forced to be only approximate in the ordinary exercise of squaring a circle, why don't you admit that uncertainty must rule over every moment? Oncologists and allied clinicians may argue that while treating a patient, they do not have to bother about squaring a circle. Fair enough. But they cannot connive at the unrecognized hollowness of much of their science and the phoneyness of much of their technique.
From a global survey of treated versus untreated cancers at various sites, Hardin Jones, of the National Cancer Institute, USA, arrived at a sober conclusion way back in 1956, but valid to the dot in 2009: "It is most likely that in terms of life-expectancy, the chance of survival is no better with than without treatment, and there is the possibility that treatment makes the survival of cancer cases less." Jones stands validated - and will be so for ever - if we juxtapose the uncertainty of the harm that a cancer would do to its bearer and the certainty of the harm that every therapy would inflict on the patient. It is an intellectual exercise through which even the blind can see clearly.
Firstly, the discreet silence, the innate wisdom of a tumour is now scientifically, cytokinetically recognized. A tumour takes a decade or two even after its start, before it dis-eases the bearer. So its track record is undeniably good. Having dis-eased, there is no certainty that it will be responsible for death. Now let this be "attacked" by what have you, and you certainly unleash spread of the tumour by the swipe of your knife, you kill for sure a million normal cells before you may kill a cancer cell, that the hormones you give may assuage the tumour, but kill the person by accelerated aging and cardiovascular disease. The above juxtapositioning allows you to arrive at a generalization Powers did in 1972 that, the deterioration of the body from disease, especially can- cer, proceeds further than it would without medical interference.
The above can be summed up in the telling words of Dr. Arthur Bloomfield, who enunciated them after a personal iatrogenic (doctor- made) tragedy circa 1930-36:
Every hospital should have a plaque in the physicians' and students' entrances : There are some patients whom we cannot help: there are none whom we cannot harm.
Bloomfield's rueful red light is both benevolent and bothersome, for the physician as also the patient. It poses forever a Hamletian di- lemma - to be, or not to be, treated, or be or not to be a treater. Such an irritating intellectual crisis can be resolved by analysing, and then synthesizing, some real-life situations.
Ubi desinit philosohus,
Ibi incipit medicus.
Where the philosopher stops,
There the physician begins.
Quoted by Marlowe in Dr. Faustus
The oncologist on the one hand, and a cancer-patient on the other have to steer their course through a maze of do's and don'ts, not knowing which way to go, and which way to be damned. An oncolo- gist is "tumour-oriented", seeing/attending the tumour, as something apart from its owner, a game in which the owner willy-nilly partici- pates. Both claim that, philosophy apart, something must be done. In a monetaristic/gadgetic/technocratic world, the temptation always is
- Costlier the better, forgetting that costlier may be ghastlier. A fairly clear way is available, however.
We reproduce below, verbatim, a cautionary box that has adorned numerous editions of the Oxford Handbook of Clinical Medicine . What follows is from the latest, 7th edition, (2007).
Advice to Asymptomatic Men Asking for a PSA Test
The prostate lies below the bladder, and surrounds the tube taking urine out. Prostate cancer is common in older men. Many men over 50 to whom this advice applies) consider a PSA blood test to detect prostatic cancer. Is this wise?
The utter compactness of the box-text finds a welcome expansion in Oxford Handbook of General Practice . What follows is verbatim ac- count on the same issue culled from the 1st (2002), and the latest, 2nd edition (2005).
SCREENING IN THE FUTURE
2nd most common cause of death from cancer in UK men. Prevalence is rising. Problems with screening: Incidental post-mortem evi- dence of prostate cancer is high (=80% men >75y.), very few be- come clinically evident many more men would be found by screen- ing with prostate cancer than would die or have symptoms from it; natural history of prostate cancer is not understood - there is no means to detect which 'early' cancers become more widespread; inadequate screening tests (see below); it is not clear if early treat- ment enhances life expectancy; and, peak incidence of morbidity and mortality is in old age (75-79y.) so potential years of life saved by screening are small.
PSA is routinely measured in men with urological symptoms
.Abnormal PSA is one of the most common reasons for referral to a urologist. Its sensitivity and specificity are poor. Other reasons forPSA: acute and chronic prostatitis, BHP (Benign Hypertrophy of Prostate), physical exercise, instrumentation or ductual obstruction. PSA may be normal when early prostate cancer is present. GPs are often asked to perform PSA testing by patients - explain its llimitations
before performing the test.
DRE (Digital Rectal Examination) is operator-dependent, fails to detect early prostate cancers and lacks specificity. Annual screening in the USA and Germany has not mortality.
Transrectal ultrasound (TRUS) - too expensive for widespread use.
4th most common cause of cancer death in women. Confined to 1 ovary = 90% 5y. survival but 80% are picked up at later stages when 5y. survival is = 10%. No reliable screening test. Options are USS (UltraSound Scan), measurement of CA125 and genetic screening. USS and CA125 both have low sensitivity/specificity. Genetic screening can only detect a few familial cancers. If an abnormality found on screening, laparotomy is required to exclude cancer which is unethical if specificity is not high. There is no evidence anyway that treatment at an early stage mortality. Further information will be available when a large-scale study, just begun in UK, reports in 2010.
Large Bowel Cancer
Common cause of death with a well-defined premalignant phase (adenomatous polyp). Prognosis depends on stage at diagnosis.
Patients with strong FH (Family History) of large bowel cancer, or ulcerative colitis are screened already with colonoscopy with proven benefit, but colonoscopy is too expensive for use in a universal screening programme. Possible alternative:
Faecal occult bloods (FOBs): +ve in 56-78% patients with asymp- tomatic colorectal cancer. Malignancies detected are less advanced but uptake is disappointing. Problems: 40% are missed and high false +ves - but does mortality. Very short lead time, so frequent screening is needed. Pilot study is under way.
DRE (Digital Rectal Examination) < 40% within reach.
Sigmoidoscopy: Could detect 60% cancers. May be protective for up to 10y.
Problems - overtreatment(some polyps may never become malig- nant), acceptability of test, cannot detect proximal tumours.
From screening, the learned text deliberates on the pros and cons of treatment, in persons without symptoms or with.
Symptomless Local Disease
Controversial. 2 arguments:
a. As nothing proved beneficial, benefits of treatment are out- weighed by risks or
b. Aggressive treatment before spread is the only way to ensure cure.
The picture is further complicated as 30% men > 50y. of age dying from other causes are found post mortem to have prostate cancer - prostate cancer kills only a small minority of men who have it. The personal and economic cost of treating men whose cancer would never have caused them any problems must be considered. Options :
1. Watchful waiting - Monitor with PSA/DRE. in PSA or size of nodule triggers active treatment. At 10y. follow up < 10% will have died from prostate cancer.
2. Radical prostatectomy - Has potential for cure but in the age group most affected by prostate cancer mortality is 1.4%. Other common complications: impotence (50%), incontinence (25%).
3. Radiotherapy - May not be effective - persistent cancer is found in 30% on biopsy.
4. Hormone treatment - No convincing evidence gives survival ben- efit in early disease.
30%5y. survival. Hormone manipulation is the mainstay of treatment and gives 80% in bone pain, PSA or both and a lower incidence of serious complications (e.g. spinal cord compression) if treatment starts at time of diagnosis. Options :
1. Luteinising hormone releasing hormone (LHRH) analogues (e.g. goserlin) - sc injection every 4-12 wk. Testosterone levels fall to levels of castrated men in < 2mo. Side effects: Impotence, hot flushes, gynaecomastia, local bruising and infection around injec- tion site. When starting LHRH analogues, LH level initially which can cause increased tumour activity or 'flare'. Counteracted by prescription of anti-androgens (e.g. flutamide) for a few days be- fore administration of the first dose of LHRH and concurrently for 3wk.
2 Anti-androgens - e.g. cyproterone actetate, flutamide, biclutamide. Anti-androgens do not suppress androgen production completely. Used to prevent side effects due to testosterone flare during initiation of LHRH analogues, as monotherapy in those who find LHRH analogues unsuitable (flutamide 250mg tds - monitor liver function if used long term)and in combination with LHRH analogues to pr