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Leave Decision Making To The Experts

Column Editors Speak September 2018

Leave Decision Making To The Experts

Patients and their families and caregivers need to learn to trust what their doctors say, rather than listen to hearsay and popular opinion.

By Dr Ulhas Ganu

The question ‘Is cancer curable?’ naturally bothers patients, and their relatives and friends alike. So far, we have read several success stories of cancer survivors—thanks to early diagnosis—in this column. Here’s another incredible story of long-term survival and cure from the 90s. A competitive teenage swimmer in 1993 found it painful to lift her arm while training for freestyle swimming. A quick visit to a specialist followed by a visit to an eminent oncologist led to the diagnosis of Ewing’s Sarcoma, a very rare type of cancer that may typically occur in the age group of 10 to 20 years. Being a close family friend, I was privy to almost every step taken by the family. Since time immemorial, surgery has been the standard treatment indicated for cancer that presents as solid tumors. The concept was ‘it is better than the tumor is out of the body than inside’ to avoid further damage. With the advent of better-designed surgical instruments, refined techniques, and anesthesia, surgeries became more targeted, giving much better results. The 1950s had seen the introduction of reasonably good anticancer drugs like alkylating agents and anti-metabolites. In fact, some of these drugs are even prescribed today.

Leave Decision Making To The Experts 1
Dr. Ulhas Ganu

These drugs (chemotherapy), along with radiation therapy, added more teeth to the then existing protocol of surgery, producing more efficient results. Surgery, followed by chemotherapy and/ or radiation therapy, is defined as adjuvant therapy. The term adjuvant therapy means additional treatment for cancer given after the primary treatment to reduce the risk that cancer will come back. It may include chemotherapy, radiation therapy, hormone therapy, and targeted therapy or biological therapy.

Though not a doctor, everyone considers themselves capable of giving medical advice to others! When relatives discussed the matter, my friend was worried that instead of surgery the consulting oncologist advised chemotherapy, to begin with, to be followed by surgery, which would be further followed by radiation and chemotherapy. The worry was a combination of mixed feelings, not because they distrusted doctors but because it defied their belief as a common man in surgery as primary therapy.

As a researcher, I knew of the then newly developed concept of giving chemotherapy prior to a surgery called neo-adjuvant chemotherapy. I could convince him based on two things. One, that such decisions come from a panel of experts comprising of specialists from different faculties, namely, surgical oncology, medical oncology, and radiation oncology, based on the pathologist’s reports. Secondly, the decisions are based on evidence from clinical studies. Very often, patients and relatives are not even aware of the pathologist’s role as one rarely meets them. Since it was a new concept, different from the conventional chemotherapy as followed then, it was defined as neo-adjuvant chemotherapy. The concept was applied around the late 1980s or early 1990s for bone cancer treatment.

Some cancer patients preferred waiting for the amputation of a limb (suggested so as to prevent metastasis) until a proper prosthesis was available. This delayed surgery by up to three weeks. So oncologists thought that instead of allowing time and opportunity for the tumor to grow and shed micro-metastases during the waiting period, why not start with chemotherapy which would shrink the tumor and kill circulating tumor cells as well? The early results were encouraging, and consistent improvement of survival was shown for the neo-adjuvant chemotherapy, followed by surgery, which was further followed by radiation and chemotherapy.

The results in this particular case were outstanding. After almost a year of therapy, the patient was cured of Ewing’s Sarcoma. Now married, she has been leading a trouble-free life for the past 25 years. Adjuvant or neoadjuvant chemotherapy or surgery followed by chemotherapy or vice versa are expert decisions and we shall not worry about these. Remember doctors ask for desired diagnostic tests and decide the course of therapy based on evidence-based medicine. Faith in them is the most important contribution to the patient’s family.

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