Over the years, the more I dealt with cancer patients, the more I came to realize what a different experience it was from the rest of medicine. I've become convinced that this disease and its related psychosocial issues create a unique mind-set that is often characterized by almost palpable dread and fear. Whether justified or not, cancer is viewed as more serious than most other afflictions, and it follows that the stakes are perceived to be higher. It is intuitive to me, then, that the health care providers who serve these patients must be more perceptive,intuitive, sensitive, and communicative than average. The oncologists and their teams must be alert to subtle signals of fear, anxiety, and depression. When these problems are recognized and dealt with, the cancer experience is much more tolerable.
Keeping these matters in mind, I will pose key questions as we go along: What should a cancer patient reasonably expect of the system, the cancer team, and especially, the cancer physician? What should a cancer physician be able to expect of the patient? What are the physician's responsibilities to the patient and to their family? How much information about the disease is enough; how much is too much; and importantly, how much is too little? Wheredo optimism and encouragement end and the gravitas of pragmatism and realism begin? How specific and how graphic should the doctor be? Is pessimism allowed, and if so, should it be shared with the patient? How forcefully should the case be made for there commended treatment; that is to say, should the physician attempt to alter the patient's search for autonomy when they are disinclined to follow the physician's recommendations? What is the cancer physician's role when treatment fails, or when no treatment is given because of the advanced state of the disease? How important are quality of life and quality of death; and specifically, what is the cancer physician's role in the dying process? Is death solely within the dominion of spiritual forces, or is there a place for the physician as a taker of life-that is to say, the catalyst to death? And if not an active player, should a physician even introduce the possibility of patient- induced death, that is, suicide? The oath that we have lived by clearly says "No" to the taking of life by the physician, but should this part of the oath be adapted "in search of modern relevance"? That certainly has happened in several European countries, and in three states in America (Washington,Oregon, and Montana), in which there are laws condoning varying degrees of physician involvement with induced patient death. Finally, because of the natural instinct for self protection, is it justified for the cancer physician to remain emotionally detached, and in doing that, not provide an intensity of feeling that might be more helpful to the patient during treatment and even on into the dying process?
These questions and many others randomly flow through the lexicology of cancer management. The answers often cannot be rigid because so much of human nature varies from individual to individual-patient and physician alike-and there should be a somewhat tailored approach for the individual patient. With that said, however, a pattern of consistency ideally should underlie it all, and the standards by which all of these questions are answered should be set by a medical profession that understands and advocates what is right as opposed to what is wrong;that is to say, an altruistic model.
There are approximately ten million people living in the United States who have had cancer, and each year, 1 and 2 million new patients are diagnosed. These people, their families, and the doctors with whom they interface provide an audience much in need of dialogue.
Roy B. Sessions, MD,FACS