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Everyone recognizes the word "cancer," but the general ignorance of early symptoms and the effectiveness of treatment can be astonishing.
I recall a situation—about fifteen years ago—when I was a first-time guest on an all-male fly-fishing trip with a group of very successful businessmen. We had had a wonderful day of trout fishing in an absolutely gorgeous Colorado stream—the food and drink made a perfect end to the day, and the men sitting around the table, could not have been more interesting and enjoyable. One man—I’ll call him Bill—a well-educated and very intelligent fellow, a combat veteran of World War II who was the quintessential example of the American success story—looked at me over his umpteenth glass of wine and said that he had been told that I was a cancer surgeon. After I confirmed that, he stopped smiling and took on a challenging expression, whereupon I braced myself for an unfortunate story about a doctor’s effort gone amuck. “Now, doc,” he said (up until then, I’d been Roy), "we’ve all had a nice evening, shared food and drink as a part of community and friendship, and since you now are certain that you are among discrete friends, you can tell us the real truth, can’t you?” “Absolutely,” I responded, not knowing exactly what to expect. “Isn’t most of the data,” he queried, “and most of the optimism about improvement in cancer treatment fabricated? Let’s be real, a cure is the exception rather than the rule, right? And basically, you don’t really expect to cure people, do you?” I was stunned, and started to respond as if to humor, when I realized that he was totally in earnest, albeit not quite sober. Looking around, I got no help from the group in dealing with this alpha male, so I tried only to rectify his state of knowledge. I got about thirty seconds into Cancer Treatment 101 when Bill politely interrupted to say that he was dying of lung cancer, and his doctors had offered him no hope for cure. I stopped my tutorial and tried to exit the conversation gracefully, but it was hopeless. After a silent pause, Bill lit a cigar, and raised his glass to toast the excellent fishing of the day. He had not heard a word I said. End of attention span! End of subject! Period!
Obviously, this is an extreme example used to make the point, but it is unembellished and a true story. The point is that if Bill believed even part of what he incorrectly verbalized, one can only imagine how many elderly people—less worldly, less intelligent, less educated—must be just as ill-informed. The fact that he had been diagnosed late in the disease may well have been related to inattention to his own health, and that may have resulted in his lack of faith in the medical profession in general; however, he was beyond cure and in his mind that was the norm, rather than the exception.
Had I thought it would have served any useful purpose, and given the opportunity, I would have pointed out to Bill that most cancers, including lung cancers, are much more treatable than he described and, yes, curable when detected early in the course of the disease. Such is not always the situation, but in general, there is a linear relationship between time of diagnosis and survival. That is to say, the earlier, the better. Even more important, today we cure many cancers; of the almost 1.5 million new malignancies that are diagnosed in the United States each year, over 65 percent will be alive and well five years later. In fact, there are approximately 12 million Americans living with a cancer history who are free of disease.
Bill’s story is not rare. I have talked to many elderly people about this subject, and I’m struck by how many are misinformed on cancer-related issues. Admittedly, in this era of information technology, this state has become less so, but ignorance and misinformation continue to be pervasive. As in Bill’s case, there are complicating factors that help develop such a mind-set—his probable feeling of guilt for having smoked heavily for many years despite knowing better, and his lack of confidence in the medical profession, which probably partially resulted from the fact that, as I later learned, both of his parents and a sibling had died from cancer.
The experience with Bill was eye-opening for me, and I have since developed more tolerance and understanding not only for people’s lack of knowledge but for the influences of life’s experiences on their behavior and attitudes. Turning around that state of ignorance is a critical part of the job of the oncologist, and the money spent by the profession’s leadership in its institutional outreach is a wise and foresighted expenditure. Cancer prevention is obviously less expensive in the long run than cancer care. Such sources as the National Cancer Institute (NCI) database and the various websites of organizations such as the American Cancer Society are more and more available to a public increasingly facile with computers. NCI has an online journal called PDQ (Physician’s Desk Query) that is cancer specific, and that is written for the education of the lay public.
Ignorance of the differences between chemotherapy and radiation therapy, as well as preconceived notions and fears related to each (and surgery, as well) are common among the general public and especially in the elderly. It has been my observation that between the therapies, the image of chemotherapy suffers more. Historically, chemotherapeutic drugs were often viewed as agents of desperation invariably associated with hair loss, skin irritation, nausea, and vomiting; basically, with some exceptions, chemotherapy was thought to complicate rather than aid in the last part of life cut short by cancer. While there are still circumstances in which the administration of these agents is a challenge for the patient, the contemporary modus operandi of the sophisticated cancer team contains medical oncologists (i.e., a chemotherapist) who accomplishes far more with less morbidity than ever before. Although a number of cancers are treated with plans that do not involve these agents, the cancer team discussions usually include the input of this important line of defense in the cancer war. It should be noted that a number of malignancies—certain sarcomas, lymphomas, leukemia, and others—are attacked medically, rather than with surgery or radiation, and chemotherapy or biologic therapy as the front line of treatment, cures many of these patients.
I’ve written in previous blogs about what a patient ought to be able to expect of a cancer physician, and in doing so, have unambiguously laid the educational burden of the individual patient on the treating physician. Oncologist must educate their patients about their respective disease and its treatments. On a more global level, however, the education about cancer related matters – early signs prevention, environmental matters—more appropriately are borne by the medical profession. Getting an increasingly modern and information technology-savvy public to take advantage of the educational opportunities is another matter, however. Just as I have challenged the profession with its important responsibility, I am now doing so with the public and especially the civic leaders. Such education is a long and tedious process that requires time, patience, and money. One need only to look at the prolonged campaign against smoking that first really started as a whimper, but gained momentum in the 1960’s, and has gradually pushed the public into dramatic behavioral modification. The results are obvious—substantially fewer people smoke today, and the benefits of better public health as a result will become more and more obvious as rationing and money distribution play an increasing role in the evolving health care system. Public education on cancer related matters should become part of our everyday charge, starting with young school children, and just as with the smoking issue, the profession and corporate America should assume the leadership.
