The Course of an Illness

The Course of an Illness

Until the beginning of the 20th century cancer could reasonably be considered an acute illness.  Diagnostic opportunities were limited and patients reached their doctors in the late stages, often exhibiting painful symptoms. Treatment options were also limited – radical surgery, which often wasn’t possible due to the widespread progress of the illness, or radiation. Therefore, the patient usually died not long after visiting a doctor. Since those days, society still views cancer as a fatal illness or a death sentence. What’s changed?

In the past half century, diagnostics and their availability have significantly improved, leading the way to better possibilities of discovering a tumour in its early stages. Essentially this has been the greatest achievement in oncology, which has affected the field’s worst indicators – mortality. Thanks to all of the pharmaceutical industry’s achievements, we can now prolong life, reduce the masses of tumours and improve quality of life, but unfortunately we still can’t protect patients from death as a result of this disease. Many diseases that often caused death, such as tuberculosis, can be treated and are no longer fatal. The same can be said of hepatitis C. No matter how expensive those treatment drugs are, these patients have hope that they can be cured and eventually return to a normal life. This is not the case with a tumour and currently even large sums of money aren’t enough to save patients with an advanced or metastatic disease.  On the other hand, data from extensive studies on the role of adjuvant chemotherapy reveal that its positive contribution to extending five-year survival has fallen far below expectations.

Not unlike an essay, cancer can also be conditionally divided into three parts – an introduction (the beginning), a discussion in the body of the work and a conclusion.

The beginning of an illness

Unfortunately, right now we don’t have a fool-proof method that can retrospectively ascertain when the first malignant tumour cell was created and when it began its triumphant march throughout the body. This much we do understand, that if we could conquer this first (stem) cell, the tumour would never develop to become the cause of death for so many people. Today this is a lottery – tumour cells kill our immunity (neutralize it, make it incapable of multiplying, etc.) or overcome all of our body’s barriers and spread further. Currently one of the most realistic scenarios is to diagnose the tumour early enough, while it’s still possible to completely cure it. For most tumour masses this can be achieved with an operation, radiation or, for cancers of the blood, with chemotherapy. Cancer screenings and other early diagnostic campaigns, such as the so-called Green Corridor in Latvia (more on this topic in another series of blogs), can help to catch the cancer in its earliest stages.

Regardless of whether the disease is discovered in its early or late stages, the expected treatment methods should be reasonably balanced with the potential risks. We don’t want to create a situation whereby, in an attempt to kill every last cancer cell after a radical operation, we cripple the body’s natural defences needlessly extending the time it needs to recover. This opportunity (when the body is weak) is often used by the remaining cancer cells to clone new cells that did not respond to the original chemotherapy. Thus, after a radical operation or radiation session, it’s imperative to consider how to strengthen the body. This requires flexible thinking from your doctor. We must remember that the diagnosis of a tumour, surgery and/or radiation therapy are themselves severe psychological and emotional shocks that can affect much more than our immune system.

On the other hand, patients with advanced cancers require an especially careful approach to ensure that an excessively aggressive therapy doesn’t make an already bad situation even worse. We currently have an extensive pharmaceutical arsenal at our disposal, so doctors have plenty of options to choose from.

Discussion

One could imagine the course of an illness as the flow of a river with steep or gently tapered banks, calm or turbulent currents, clear or tempestuous water. Where to stop? How one steers their lifeboat through the harrowing rapids of their illness is a matter of both luck and destiny. My experience tells me that for some people this journey will be calm, yet stormy for others and this isn’t always dependent on the location of the tumour or the stage of the disease. The prognosis is the most mercurial part of an illness, but we’ll cover that in another blog.

Cancer is no longer a disease from which you die a quick and agonising death. Today most cases could be characterized as a chronic process with highs and lows. I know of many patients who have experienced recurrences of cancer over and over again and each time they’ve received treatment and continued living their lives. Other patients have even developed a number of different tumours, which were all treated successfully. Unfortunately, each patient’s individual course of illness isn’t tattooed on their forehead, so doctors often have a difficult time coming up with a prognosis. Each case is so individual, that it’s even possible that faith solely in evidence-based methods could lead to an unwanted result. What’s of paramount importance is the level of trust between a doctor and patient. This must be without prejudice (this is madness, he’s still using homeopathy!), mistrust (does he really think he can cure his cancer by drinking lots of juice!) and judgement (if you continue to use folk remedies, don’t bother coming back for an appointment!). In the end, the most important thing is for the patient to be alive and satisfied with his quality of life. This last comment is especially significant, especially when we read about extremely expensive wonder drugs, which actually only prolong life by a matter of a few months, yet bring with them painful and severe symptoms or unwanted side effects that are often associated with these drugs.

The conclusion

This is a philosophical question – when a cancer patient sees the end of their life’s journey. For one person the beginning of the end may be receiving a diagnosis, for another a recurrence of the disease, while a third may consider it the end when they become feeble, reliant on others and in constant pain from agonising symptoms. The most difficult part of this story is when you accept your own mortality or as the Latvian poet and playwright Rainis wrote: “The devil and the dead – neither die, Only people – they’re weaklings!”. We all want to live long and happy lives, and this is also true of cancer patients, but this isn’t always the case. To resign yourself to this fact is exceedingly difficult. Marketing campaigns often take advantage of this, promising life-saving drugs and a way to reclaim your life for your family and children. Oncological illnesses are a very sensible topic of discussion for society and well-meaning people try in good faith to raise money for their plight through a number of charitable organisations, but an oncologist like me only sees a desperate tilting at windmills. Unfortunately, money doesn’t guarantee a cure. It’s possible that I may offend some of my readers when I say that doctors often commit a cardinal sin against their patients and family members by not telling the truth. The question isn’t whether or not to tell someone, but how to tell someone. To know how to motivate even in this dire situation and to help them understand that even a short time can be invaluable and full of life for the patient and his loved ones.

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