Despite an abundance of methods to estimate prognosis, the ability to predict a cancer’s behavior – to tell a patient that they will be cured if they receive treatments X, Y, and Z – is still an inexact science. This brings us to the fifth and final factor that determines prognosis. It has no official name, but I call it the biological essence of the cancer.
It is truly the key to a cancer’s behavior, even though we cannot measure it at this time. The biological essence comes from deep inside the cancer cell to dictate how heartily it grows, how well it resists apoptosis, and how invasively it spreads throughout the body.
All of the properties we have discussed thus far are mere surrogates for this biological essence; they all try to approximate it but fail to truly capture it. For example, how could it have been predicted that a fifty-year-old woman with an early-stage lung cancer (stage I) would ultimately die from lung cancer that returned more aggressively? And how could it have been predicted that a forty-two-year-old man with colon cancer that had spread to the liver and lungs (stage IV) could be cancer free five years after chemotherapy, when the average survival of such patients is under two years?
Neither cancer type, stage, health of the patient, nor prognostic factors could have predicted these outcomes. These cases highlight the reality that there is much that science cannot explain about the behavior of cancer.
In scientific circles one often hears the phrase “Biology is destiny.” This statement means that it is the innate biological properties, or biological essence, of a cancer that most strongly determines how it will behave in the body. For example, why is pancreatic cancer so difficult to treat? Its biological essence leads it to metastasize early and respond poorly to today’s cancer therapies.
Why is testicular cancer so often cured? Its biological essence makes it melt away with chemotherapy or radiation. When a cancer patient lives much longer than could have been anticipated, the main reason is thought to be the favorable biological essence of that cancer: it grows slower or succumbs to treatment more easily than other cancers of its class.
I have talked to enough people about cancer to learn that many know someone who defied the odds and overcame an “incurable” cancer. Certainly, in my small oncology practice I am a cardiothoracic surgeon), I am continually amazed at how some people survive for many years with a cancer that has a dismal prognosis; the treatments worked incredibly well. But beyond the treatments, do I think that some people have a special gift, have found a cure from a healer, or have prayed harder than those who succumbed to cancer?
Maybe. I have had the immensely humbling privilege of caring for some of the most courageous, health-conscious, and devout people that anyone could ever meet; many of these individuals faced an insurmountable enemy in a cancer that just could not be beaten down. And whereas some individuals try to do all that they can to fight cancer, there are those who do not want to change their lives any more than they have to.
These individuals accept the prescribed therapies but continue their life as uninterrupted as possible. This is also an important coping mechanism that must be respected. As British author and cancer patient John Diamond wrote in Because Cowards Get Cancer Too, “[I . . . hate] the sort of morality which says that only those who fight hard against cancer survive it or deserve to survive it – the corollary being that those who lose the fight deserved to do so.” The reality is that the biology of a cancer plays the largest role in determining why some people are cured and some are not. A person’s physician and the treatments administered are clearly important; new and better cancer therapies are changing cancer’s destiny in many situations.
Other factors that may help a person survive include stopping smoking, eating a healthful diet, getting adequate rest and exercise, lowering stress, accepting love and emotional support, and having the will to live. But these cannot overcome an aggressive cancer for which modern medicine has no answer.
By acknowledging the reality that the molecules inside the cancer cell largely determine a cancer patient’s prognosis, I do not mean to minimize the tremendous powers of the human mind, heart, and spirit.
On the contrary, I would not have been compelled to design this course with a oncologists colleagues if I did not believe that these uniquely human traits play a vital role in the healing of the human body. Yet the cancer’s biological destiny will largely determine the course it will take.
Since we cannot predict this destiny for any cancer, any discussion of prognosis must be accompanied by the caveat that every person and every cancer is unique and that this uniqueness is poorly understood today.
Our ability to provide a highly accurate prognosis to a newly diagnosed cancer patient will depend on advances in science that are able to capture the biological essence of a cancer.
Incredibly, these advances are happening today, and we stand at the crossroads of a new era in the field of cancer medicine. Within the next ten years, the diagnosis, estimation of prognosis, and treatments used to battle cancer will all be much more precise than they are today.
