A Few Things To Consider While We Work on the Eradication of Cancer

The evolution of treatment options for solid tumors has followed an extraordinary path in the last 100 years; from a potentially curative option obtained from surgical resection to current multimodal protocols offering cure or prolonged survival.  Interestingly enough, various and global rates of survival have increased for many reasons including early detection through screening programs, management of environmental factors (still in progress) but also because of treatments based on chemicals and radiation.¹ For a long time, the essential question was: “Can my cancer be removed so I will be cured?”  A simple and important question, the answer NO allowed patients and family to focus on what life remaining, regardless of the duration. The evolution of the question of curability or not, a binary response, is blurred.

Is preparation for death still a concern? The complexity of multidisciplinary and multimodal treatments and associated successes increased while the idea that death was no longer a valid topic of discussion but a failure.  Life as quantitatively measured had to be pursued at any price human and financial.² The focus on quantity of life, whatever that means, hides the evaluation of quality of life.  Does it have to be this way?

Societal concerns about life, in general, have evolved and the importance of quality of life too often rests second to the number of days gained, as revealed in medical but also lay press. The medical community has to adapt and address death as a valid personal and societal concern and restore the center of attention from what we can do to patients to what we could do for them and assist them to make an informed decision about their life and their death.  A PubMed search generated with the keywords surgical oncology and palliative care retrieved 1,620 references since 1964 with a steep increase in academic production since 2003 where more than 1,000 articles have been published. The focus of many of these articles is the role of patients’ choice in face of the, sometimes directing, voice of the medical team, on occasion offering unattainable goals or mediocre gains of days of survival; hence, limiting the choices of our patients when they possibly should focus on the end of their life if they had been informed properly.^3,4

Operational capacities to offer adequate end-of-life and palliative care management do not match the resources, human and technologic, to cure and manage tumors available in many cancer centers.⁵ Integration of palliative care options should not be a choice determined by considerations other than patients’ management; fortunately, this is finally getting significant traction and acceptance.⁶   If we acknowledge the mediocrity of palliative care education in non-dedicated palliative care fellowship, we might accept that significant change will come from practitioners currently in training following anecdotal change generated by pioneers over the last decades.⁷

Over the last 100 years, technology and science have helped patients to be diagnosed early and survive cancer. It is time to focus equally on how patients live and die when a cure is no longer an option. This is probably the most important part of our duty when we discuss prognostication and treatment options.  As Eduardo Bruera, MD, @edubru, wrote with the space constraints of a tweet: “Why do medical and academic leaders offer universal med onc and rad onc for advanced cancer and fail to offer specialist pall care for the complex suffering cancer patients?”

References

1. “Opinion | Gains Against Cancer,” The New York Times, October 20, 2007, sec. Opinion, https://www.nytimes.com/2007/10/20/opinion/20sat3.html. Accessed Jul 20, 2021
2. Jane E. Brody, “Cancer Treatment at the End of Life,” The New York Times, August 5, 2019, sec. Well, https://www.nytimes.com/2019/08/05/well/live/cancer-treatment-at-the-end-of-life.html.Accessed July 20, 2021
3. Timothy E. Quill and Howard Brody, “Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice,” Annals of Internal Medicine 125, no. 9 (November 1, 1996): 763–69
4. https://surveillance.cancer.gov/survival/measures.html. Accessed August 30, 2021.
5. Nadia V. Guardado, Kaysey Llorente, and Benoit Blondeau, “Evaluation and Management of Malignant Biliary Obstruction,” Surgical Oncology Clinics of North America 30, no. 3 (July 2021): 491–503.
6. Bridget N. Fahy, “Introduction: Role of Palliative Care for the Surgical Patient,” Journal of Surgical Oncology 120, no. 1 (July 2019): 5–9.
7. Erin M. Sadler, Philippa H. Hawley, and Alexandra M. Easson, “Palliative Care and Active Disease Management Are Synergistic in Modern Surgical Oncology,” Surgery 163, no. 4 (April 2018): 950–53.
8. Albert Amini et al., “Palliative Care Training in Surgical Oncology and Hepatobiliary Fellowships: A National Survey of the Fellows,” Annals of Surgical Oncology 22, no. 6 (2015): 1761–67.