Ending the “war on cancer”

Notice where I put the quotation marks in the title. This post is not about the state of the union of cancer research. It is about an article published in Nature last week by Colin Macilwain that argues we need to move beyond the ideal of fighting a “war on cancer” and build a more constructive approach to cancer care. I agree wholeheartedly with Dr. Macilwain.

Cancer is not one disease. It is hundreds of diseases from breast cancer to prostate cancer to blood-borne malignancies like leukemia. These diseases are as different from each other as coronary artery disease is from atrial fibrillation. Yet no one argues we need to fight a unified “war against heart disease”. I follow the cancer research community fairly closely, and I am not aware of a single researcher trying to find a unified cure for cancer. We take small steps at a time with occasional paradigm-altering breakthroughs, such as the development of Imatinib (Gleevec) for chronic myelogenous leukemia (CML). Instead of holding out hope for a single “cure” for cancer, let’s talk about what can be done.

In the immediate future, several ideas, if put into action by the government (which for me is the Ontario provincial and Canadian federal governments), could significantly help cancer patients. First, all oral cancer chemotherapy pills should be provincially funded instead of bankrupting Ontarians by making them pay out pocket thousands of dollars a month (see here for more). We need a clear plan to expand and provide access to palliative care for all patients who are near the end of life. And for those suffering terribly despite palliative care, the federal government needs to get their act together and come up with sensible laws to provide access to physician-assisted dying (the majority of the small number of patients who seek assistance in dying are people with cancer). Finally, although not related to any government action, the medical community and the media need to stop using cancer as war metaphors. It is insulting to people who succumb to the disease when it is said (or written) that someone else “successfully battled cancer”. The outcomes of the disease are not related to how “hard” people try to “fight” the disease.

In the intermediate future, we need to continue the expansion of regional cancer centres in order to provide local access to surgical, chemotherapy and radiation treatments. We need to continue to encourage innovation and trials of novel therapies in an attempt to attain significant changes in cancer prevention or treatment.  One recent example from the Princess Margaret Cancer Centre (where I train) is a study that showed that pre-operative radiotherapy more than doubled the survival rate (from 32% to 72%) for mesothelioma. What we do NOT need to do is waste over $3 million (and give false hope to patients) in studying “naturopathic” or “integrative” oncology. I’ll tell you right now (free of charge): acupuncture, massage, and intravenous vitamin C does not help cure cancer.

Finally, in the long term, we need to focus research efforts (and funding) on the types of cancers with the worst outcomes (pancreatic, lung, ovarian just to name a few). Prevention of these cancers would be wonderful but a more realistic goal is the early detection of these highly deadly diseases. We need to improve how we detect cancers that already have screening tests (like breast and prostate) by better determining who truly needs treatment and who doesn’t (“active surveillance”) as well as how aggressive we need to treat each individual.

These are just a few ideas, some of which I hope to expand on (through writing or my actual research) in the future. But for now, let’s stop thinking of cancer as a “war” that needs to be fought and think about how the medical community can best support people afflicted with this terrible disease.

A day in the life: palliative radiation oncology

This is the first post in a running series where I describe a typical day in the life of a radiation oncology resident on a particular rotation, obviously from my own viewpoint. It seems to me that friends and family, as well as resident colleagues outside of oncology, don’t really know much about radiation oncology or what radiation oncologists do day to day and how we help patients. I’m hoping this series will shed some light on the specialty.

*Also please note that the patients described below are NOT actual patients but are fictional situations I routinely encounter.

I start my day around 8:30 am, when I finish preparing (I usually start the day or night before) for the patients I will be seeing that day by reading previous consult notes and reviewing their test results. In the morning there are typically 3-5 new referrals for palliative radiation and I typically see two or three of them. At 9 am I see a man in his seventies with a diagnosis of metastatic prostate cancer who was admitted to hospital overnight with back pain and leg weakness, and in whom an MRI of his spine showed spinal cord compression (tumor pressing on the nerves running up and down the spine). This is considered a radiation oncology emergency and after taking a full history and performing a physical exam, I will report to my staff and together we will carefully review all the imaging scans taken to date (which may include plain x-rays, bone scans, CT, PET or MRI scans). We will “consent” the patient, meaning explaining in detail why we are offering radiation to the spine (to help shrink the tumor to alleviate the compression on his spine), how it is given (one treatment per day for five days) and the side effects (pain getting worse the first day before it gets better, nausea). We then schedule his “planning” CT scan (so we can tell our radiation machines where to aim the radiation) for later that morning and his start of treatment (for an emergency such as this we start the same day, usually in the late afternoon). We also optimize his medications (giving a steroid, dexamethasone, to reduce the inflammation caused by the tumor in the spine, an anti-nausea medication, and sometimes altering their opioids for pain management).

By now it is 10:30 am and I go see my second patient of the day, a young woman in her fifties with metastatic breast cancer with progressively worsening pain in her right ribs and chest. After another history and physical exam, I review with my staff not only the CT scan and bone scan but the details of her previous radiation treatment to her right breast in comparison to where we propose to give radiation now to ensure there is no overlap (if there is overlap it may not be safe as re-irradiation can have toxic side effects). I organize a CT scan for noon but have to wait to schedule her radiation treatment until after I email her medical oncologist to discuss scheduling her radiation between cycles of chemotherapy in order to avoid increased side effects when chemo and radiation are given too close together. I may also put a wire on the patient’s skin in the area of pain to help me determine where to give radiation since rib metastases can sometimes be difficult to fully appreciate on planning CT scans.

The rest of the morning is spent scheduling and documenting these encounters on three different hospital computer systems and dictating notes on the phone. After lunch and/or educational rounds I go to the “planning” area to “contour”, which means outlining (by drawing with a mouse) the tumor seen on the CT scan (the one acquired that same day) that is causing the patient’s symptoms. After some other boring technical details regarding how to expand the contours to ensure the radiation has its intended effect, I sit down with the radiation therapist assigned to this case and describe the clinical situation and what I have contoured. The therapist (or “planner”) will then design a way for the radiation beams to be organized in order to physically provide radiation dose to the tumor that was contoured while minimizing radiation to the healthy surrounding tissue and organs. There is a time crunch for my patient with spinal cord compression since his radiation is starting in a few hours and the contours and final radiation plan has to be approved by the staff radiation oncologist (an MD) and reviewed and approved by a medical physicist (a PhD) before the plan is uploaded to the treatment machine. I do the same thing (but without the time crunch) for the patient with rib pain, but in her case we (the entire team involved) have to be extra careful to give radiation to the tumor in her ribs while avoiding overlap with her previous breast radiation, and minimizing dose to her right kidney (which is in the same vicinity) as kidneys are highly sensitive to radiation and we do not want to damage them and cause impaired renal function.

The rest of the late afternoon is spent doing miscellaneous activities. Most days I will take one or two calls from doctors at our affiliated hospitals (in internal medicine, urology, thoracic surgery, medical oncology, etc.) for patients they believe would benefit from palliative radiation. I triage the urgency and help organize who/when/how the patients will be seen. Once or twice a week I will walk to the hospital across the street or a few steps down the road to see an urgent consult and go through the same process (history, physical, organize CT scan and treatment, and contour). I also return calls from patients at home who recently completed radiation who have concerns or side effects of radiation, and review any test results (usually CT or MRI scans) I had ordered for patients I had seen previously.

By now if it’s not past 5:30 I will go pick up some or all of my children from school or daycare and head home, except for the once or twice a week I am on call in which case I will take over the responsibility for the inpatients admitted to radiation oncology (typically 15-20 patients) until 9 am the next day.