Tuesday 19 February 2019

Cancer’s long-term prognosis: As an oncologist I’ve never been so hopeful

As a new year dawns, doctors and patients everywhere can take heart in the good news

“You’re an oncologist, isn’t that depressing?”

Answering this question, posed with equal parts dread and fascination, is an occupational hazard.

I often reply no, I don’t find it depressing but the job is taxing in a way that many other areas of medicine are not. A cancer diagnosis is obviously frightening for the patient but each time, it also signals the start of a new journey for the oncologist. It means getting to know a patient intimately, breathing someone’s hopes and dreams, helping navigate a tightrope between hope and reality, wondering all the while what “average overall survival” will look like for that individual. It means accepting that although all death is inevitable, the patients one grows to like and admire might die sooner than seems fair. More so than other medical encounters, if the journey requires resilience of the patient, it also demands that the oncologist be emotionally agile to stay the course that even in the smoothest of instances is destined to leave a person fundamentally altered.

Apart from intellectual breadth, every cancer patient deserves emotional depth: getting this balance right is the perennial challenge of being an oncologist. Nonetheless, it’s obvious that patients are willing to tolerate a lot and excuse much more in order to feel well again, but more of that later.

Last week, the American Cancer Society released its annual report with the striking news that overall cancer mortality in the United States fell by 27% in the past 25 years, mirroring figures in other developed countries including Australia, the United Kingdom, Japan and South Korea. In many countries now, more than two-thirds of patients diagnosed with cancer are alive five years post diagnosis. Lest this figure sound pedestrian, cancer remains one of the world’s largest killers and every year of survival gained buys time for even better treatments to emerge, something that I have been gratified to see in my own relatively short career.

As a trainee, I remember seeing a 60-year old man with metastatic prostate cancer and after consulting my boss, telling him there was no good drug for his disease. How could it be, he asked. I am sorry, I sympathised. Some time later, we met his wife dying from colon cancer.

 ‘Cancer patients put up with a lot in order to get well, but compassion, empathy and respect for
the individual should not be optional extras, indeed patients regard them as therapeutic as the
drugs they are prescribed.’ Photograph: Jose Luis Pelaez/Getty Images

Someone else pleaded to know if his young friend with melanoma that had spread to the brain really did not have long to live. Sad but true, I had to say. A refugee sobbingly cursed her fate at having survived the rough seas only to end up with advanced breast cancer that had few effective treatments. And one of my first patients as a consultant was a young mother with advanced lung cancer, dying at the same time as I was pregnant. This juxtaposition of life and death was disturbing enough but to not have the ability to treat her beyond the few failed therapies felt like an indictment of the profession. How could the caring profession care without the right tools?

In just over 10 years, the landscape of cancer treatment has changed unrecognisably. Oncologists are spoilt for choice in giving patients real options that extend life and maintain quality. We used to console disheartened patients that no two cancers were the same but now we say it triumphantly because the differences are being harnessed into solutions.

And what a gift it is to turn up in clinic and witness the human face of change. A father seeing his son graduate, a grandmother holding her first granddaughter, careers getting back on track, lives mending slowly but surely. And perhaps the most poignant gift of all: a healthy baby, blissfully oblivious to the miracle that modern cancer medicine and sophisticated obstetrics saw him safely into the world where once he and his mother may not have survived.

The good news is not limited to the fall in mortality; there is also the reminder that we are not completely helpless in the face of cancer. Cancer risk is modifiable through lifestyle changes that include curtailing smoking, drinking and eating processed foods, maintaining a healthy weight and taking regular exercise. Early detection through proven screening programs is a key contributor to better survival.

For oncologists and patients fortunate to live in a few developed countries, the news about cancer really does keep getting better although even there, minority status, socioeconomic disadvantage and illiteracy are associated with poorer outcomes that we cannot ignore.

But the real tragedy of cancer continues to unfold beyond the borders of the developed world. Of the more than nine million deaths from cancer each year, a staggering 70% are in the developing world due to the lack of effective prevention, screening and treatment. The survival rate for children is particularly dismal – 20% in comparison with 90% in the developed world. To add to this injustice, most cancer patients are forced to die raw, painful deaths because they lack access to a drug as vital as morphine. It is a cruel irony that while select countries groan under an opioid epidemic, the rest of the world is crying out for pain relief due to restrictive government policies and misunderstanding about the use of opioids in palliative care. Declaring any kind of victory over cancer would be to ignore the plight of our fellow citizens.

Returning to the countries that can welcome progress, what more can we do to make life better for cancer patients? For a start, better communication between oncologists and patients. Cancer patients put up with a lot in order to get well, but compassion, empathy and respect for the individual should not be optional extras, indeed patients regard them as therapeutic as the drugs they are prescribed. A good relationship with an oncologist provides the strongest basis to have difficult conversations about serious illness and mortality, an inescapable part of the oncology lexicon. Effective communication must be elevated to the same importance as proper treatment.

My most troubled patients are those who have survived cancer but lost their way in life. They can’t find a job, have broken relationships and can’t afford rent. They cannot concentrate, they hate the way they look and feel hopeless about the future. Their family can’t always understand why they aren’t just happy to be alive. They are my constant reminder that holistic cancer treatment must promise more than five-year survival.

In 20 years, Australia expects to double the number of people with a personal history of cancer to nearly two million. The UK expects to add a million survivors per decade. The US, with its much larger population, will have more than 20 million survivors within the next few years. The next challenge will be to diagnose the real challenges faced by these survivors and find ways to address the physical, emotional and personal toll of cancer which manifest long past the diagnosis. Oncologists are not the best-placed people to deliver all survivorship care, but they must advocate for its seamless integration with cancer care.

As a new year dawns, oncologists and patients everywhere can have reason for hope. Hope that good treatments unaffordable or inaccessible to many will inch their way closer to needy patients around the world through a combination of better policy and targeted philanthropy. Hope that the right to die with dignity and pain relief will be recognised as a basic human right. And hope that one day, it will no longer be relevant to wonder aloud if being an oncologist is depressing.

(Source: The Guardian)

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