The Oncologists' Guaranteed Employment
Act of 1998
Hippocrates opined "first do no harm." Osler preached above
all else "examine the patient." Salk asked us to "prevent
the disease." Which preeminent physician commanded that before
anything else, "pre-radiate and administer chemotherapy for the
tumor?" None, as far as this medical editor knows, but in 1998
this is the policy for all newly diagnosed patients with stage II-III
gastrointestinal malignancies. No surgical excision of the tumor is
to be performed before administration of weekly doses of 5-FU and daily
irradiation of the tumor. The idea in colorectal carcinoma is that the
tumor lesion is debilitated by chemotherapy and radiation. After a respite
of 6 weeks, surgical excision of the mass is undertaken, removing the
irradiated tumor. A similar strategy is mandated for cancer of the esophagus,
stomach and intestine. At one time, when a tumor was diagnosed, surgery
was undertaken immediately to explore the extent! of the tumor invasion
and spread. No more. Now CT scan, endoscopy, intra-abdominal ultrasound
stages the tumor, determines nodal involvement, and specifies metastatic
spread. A tumor that has metastasized to a distant organ almost always
disallows the normal surgical removal of the tumor. Medical strategy
limits treatment for metastasized tumors to radiation and chemotherapy,
leaving the malignant growth intact, without surgery. If the tumor has
not spread beyond the local region, surgery is in order, but only with
prior administration of chemotherapy and radiotherapy. Only if the tumor
is discovered at a superficial stage is surgery alone the treatment
of choice. Meaning that essentially all patients with cancer of the
colon, intestine, stomach and esophagus will be obligated to undergo
chemotherapy and radiation before having surgery. Sounds like a guaranteed
employment act for oncologists and radiation therapists, doesn't it?
I wouldn't have much of a "beef" about this except that this
new medical strategy has had bad results for my family and friends.
The older technique of only removing the tumor surgically worked out
much better for my family. In the 1950's my paternal grandfather had
cancer of the colon, underwent a surgical resection of the colon tumor,
survived for another 30 years. Of course, there was no chemotherapy
back then and radiation therapy was limited to other types of tumors.
In the 1960's my maternal grandfather had cancer of the stomach with
metastasis to the liver. He had a stomach resection and survived more
than 20 years. He had no chemotherapy or radiation treatment. Both of
these men celebrated their 90th birthdays! Living that long, my paternal
grandfather fell victim to cancer again. He had a new primary tumor,
cancer of the esophagus when he was in his late 80's. He was treated
with radiation treatment. He survived the radiation for a few years,
apparently not dying from metastatic cancer.
Contrast the survival my grandfathers enjoyed with two more recent
examples of "cancer management" for my mother and also for
my friend. In the early 1990's my mother was diagnosed with cancer of
the stomach. Her surgery was followed by chemotherapy. The chemotherapy
agent, adriamycin, was administered intravenously in her forearm but
leaked into the surrounding tissues causing ulceration. She required
antibiotics and a skin graft before the ulcer would heal. When she sought
a second opinion, chemotherapy was again advised, this time cis-platinum.
She required hospitalization and suffered throughout the chemotherapy
experience. She appeared to be without evidence of further tumor activity
for 4 years. Then she began to feel ill and examination revealed metastasis
to the liver. She never recovered, dying some months after being diagnosed
with tumor spread to the liver.
Last summer my friend Dave who had been suffering one or more years
of heartburn, coughed up blood. His examination revealed adenocarcinoma
of the esophagus. This diagnosis without apparent etiology is appearing
more commonly in the US among relatively young men in their 40's to
60's. He was informed that he would need to have a surgical resection
of the esophagus. However, before the surgery, he would undergo 6 weeks
of radiation treatment, 5000 rads. Simultaneously he would undergo chemotherapy
with 5-FU. As the treatment proceeded, Dave became progressively sicker,
requiring endless anti-nausea medication. He was unable to eat, losing
one pound of weight daily for weeks. The program was never completed
because Dave became too sick. Returning home, he never stabilized. When
a CT scan of his abdomen was redone, his liver demonstrated metastasis.
With this diagnosis the surgeons declined to do the surgery of the esophagus.
Dave died aft!er a progressive slow decline, watching TV at home, unable
to carry out any of his normal parental or occupational activities.
As a friend of his, I watched helplessly as the disease advanced relentlessly
through its course.
Dave never got to have his surgery. Was the tumor aggressively invasive
or did the chemotherapy and radiation disrupt his immune system, irrevocably
accelerating the tumor's progression? We'll never know. What if the
surgery was done first? Might he not have had a longer survival? Adenocarcinoma
of the esophagus is a very nasty tumor, but surgery is still the gold-standard
of gastrointestinal cancer treatment. Dave never had a chance without
the surgery. How about my mother's cancer of the stomach? Her surgery
was followed by chemotherapy. The chemotherapy was putatively to prevent
the metastasis of the cancer. It didn't work. The cancer eventually
metastasized to the liver. Are we crediting radiation and chemotherapy
with too much false hope for preventing tumor spread? One wonders how
my mother would have fared if she never had the chemotherapy. My two
grandfathers lived in an era before chemotherapy and when radiation
was not p!art of the "protocol" for gastrointestinal malignancy.
That was apparently fortunate for them; the absence of chemotherapy
and radiotherapy contributed to their survival.
Now chemotherapy and radiation is part and parcel of the protocol.
Once the cancer diagnosis confirms a malignancy, unless it is superficial,
chemotherapy and radiation is mandated before any surgery can be done.
It's not a choice. No chemotherapy, no radiation...no surgery! Of course,
in the third world, only surgery is available, so this protocol is not
a worry. Here in the US, however, expect to be radiated and poisoned.
I don't think that the cancer researchers have substantiated the case
for radiation and chemotherapy in gastrointestinal cancer. I don't think
Salk would believe that we are preventing spread, that Osler would agree
that we are understanding our patient's disease, or that Hippocrates
would concur that we are not doing harm.
We should be able to choose surgery without chemotherapy or radiation
and then seek alternatives of our choice to treat the "residual"
cancer.
Jonathan Collin, MD
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