China’s “Cancer Villages” Acknowledged by Government Report
TO CURE OR CONTROL?
Robin’s cancer story is brief, her treatment well defined. The treatment course could be mapped out for her at the outset.
If the cancer responded completely, as we had hoped, then she would not require other therapies. Although the treatment was arduous, toward the end of it, Robin could look forward to its completion and “getting on with my life.” Although cure was not a guarantee, it was a distinct possibility.
Metastatic or advanced stages of cancers treated with the strong possibility of cure (more than 50 percent of the time) include aggressive non-Hodgkin’s lymphomas, Hodgkin lymphoma, testicular cancer, and some rare tumors. Advanced stages of ovarian cancer are also treated for cure with chemotherapy after surgery; the five-year survival rate is approximately 35 percent.
Patrick’s journey is longer. It is also the road more traveled by people who live with cancer. Control of his cancer required a series of treatments given for unpredictable periods of time and in an unpredictable sequence. The different treatments available could be listed at the outset, but when each option would be used could not be foretold; it would depend on how effective each was. We could not have known that the ketoconazole would work for as long as it did; in some patients it works for a shorter time or not at all and chemotherapy is instituted sooner.
As one of my colleagues likes to tell his patients with metastatic disease, the control of their cancer will be “a work in progress.”
The key word is control: control of cancer that we do not yet know how to cure. This control is achieved through treatments given at the appropriate times over months or, we hope, years. Because good control converts incurable cancers into chronic conditions that must be dealt with for the remainder of one’s life, I will refer to them as chronic cancers.
In a small percentage of patients (usually less than 3 percent), treatment may lead to complete remission of the cancer and eventual cure of breast, lung, colon, or other cancers. But because the percentage of patients cured of “incurable cancers” is so low, most oncologists refrain from mentioning this possibility out of fear that such information could give their patients false hope and unrealistic expectations. In my practice I do discuss cure as a potential outcome (and always hope for it), although I emphasize its rarity; if the cancer remains undetectable as time marches on, a patient will find that his or her oncologist is more receptive to a discussion of cure.
Despite the above, extensive research has so far failed to find easy cures or even difficult ones for many cancers. Efforts to blast away metastatic cancer with mega doses of chemotherapy have fallen short because they do not root it out but rather cause more harm than good: the cancer is still present and the patient is sicker than ever. Not surprisingly, those cancers that can be cured by such an approach are the ones most responsive to standard doses of chemotherapy, namely the blood and lymph cancers (high-dose chemotherapy followed by return of one’s own blood stem cells, to reconstitute blood formation, is an effective treatment for multiple myeloma and relapsed lymphoma, as well as some cases of testicular cancer and pediatric cancers).
Ultra-aggressive efforts that have failed to cure metastatic cancers have given way to smarter ways of administering cancer treatments that are both more effective and less toxic.
These new efforts include: (1) the use of smaller doses of chemotherapy given more frequently; for example, one can give a hundred units of a drug every three weeks or thirty-three units weekly (as long as studies support their equivalence). The lower dose given more often tends to be less harsh on normal tissues, but the tumor “sees” the same total dose intensity over a three-week period; and (2) the development of targeted therapies that, by blocking specific pathways of cancer growth, enhance the effectiveness of chemotherapy.
When Chief Justice William Rehnquist was diagnosed with aggressive thyroid cancer and at the age of eighty returned to work rather than retire, many in Washington and the media were shocked. This prompted New York Times editor Janet Battaile to write a piece entitled, “Very Much Alive, Thank You.” Battaile disclosed that she was very much alive and a five-year survivor of multiple myeloma currently under treatment with thalidomide. She wrote about a number of prominent legislators and judges who were also working and thriving while receiving treatment for cancer; they called themselves “the chemo kids.”
There is no doubt that oncologists like myself the world over are caring for an ever-growing number of inspiring individuals who are living longer and better despite harboring active cancer. Our community cancer center is a bustling celebration of life rather than a somber, sterile environment; the struggle is evident and emotions are raw at times, to be sure, but an atmosphere created by genuine human warmth and caring makes everyone’s task lighter.
It is not my intention to paint an overly rosy picture in which all patients with such cancers are now living many years. It is no secret that Judge Rehnquist did eventually die from his cancer. As an oncologist, I have the frankly disturbing but solemn responsibility of caring for too many people who lose their life to this disease. It is not acceptable that we cure too few advanced cancers.
Even though billions of dollars are invested in cancer research every year, most new drugs in the research pipeline will extend life rather than be silver bullets that pierce the heart of cancer. But this is still progress (the money is well spent!), and it is important to keep in mind that, by their very nature, advances in research are incremental. We are always elated, of course, when the murmuring momentum of research is jolted by a breakthrough that dramatically improves the lives of those battling cancer.
Between hope and hype, there is reality in which research gains are hard-won and modest and cancer must be battled with grit. This is the fight of your life.
