The Oncologists' Guaranteed Employment Act of 1998 By Jonathan Collin, MD

[Guest guest]

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