Cancer is a major cause of morbidity and mortality. In France, it is the first cause of death among men. In the UK, the latest office of national statistics infographic illustrates the rise in the incidence of lung cancer among women.
Huge progress in cancer survival rates has been observed in recent years, mainly down to early detection of the disease and advances in treatment. Screening programs have played a key role in improving the stage at which cancers are now diagnosed, the earlier a cancer is caught, the better the chances of successful treatment. But there is growing concern about whether drastic cancer treatments such as prostectomy or mastectomy are being carried out unnecessarily, leaving people with chronic discomfort and functional limitations as articulated in a 2013 JAMA article. When due consideration is given to a patient’s other health conditions, their age, and obviously the type and stage of their cancer, the resulting treatment recommendation for a cancer could be: ‘Watchful waiting’.
As a person with a cancer, how do you feel about being told to wait… watchfully? What is it like to hear we will not treat your cancer, but monitor its evolution? In other words, doctor, you suggest we do… nothing.
But there is mounting evidence that watchful waiting may be the best approach under certain circumstances.
A recent study analysed data on the diagnosis and treatment of prostate cancer. The authors show that radical prostectomy was carried out more often than it should have been, resulting in increased suffering and discomfort in patients than if nothing had been done at all. They conclude that appropriate treatments for older patients and those with other illnesses are needed, taking the patient’s overall life expectancy into account.
Cultural representations of cancer are strong and loaded with morbid imagery. Cancer is a killer – a monstrous invader colonising your organs cell by cell. Cancer leads to lengthy suffering and pain, remission followed by yet another diagnosis, and eventually death. It is lethal. So how can someone listen to a doctor propose to sit-back and watch them live with cancer?
The screening and treatment of cancer have evolved more rapidly than our cultural representations of the disease. When presented with treatment options, it is understandable for a patient to want the disease to be cut out of their body. But under certain circumstances this may cause them more harm than doing nothing.
On the other hand, medical technologies have lead to the heavy use of diagnostic screening tests, exploration and imagery. One BMJ article suggests that the medical culture of ‘staving off death’, along with powerful financial agendas increasingly present in the medical and pharmaceutical industries are such that there is no incentive to push for less aggressive treatments.
Nowadays, the doctor-patient relationship is supposedly more ‘patient-centred’. The medical establishment is, therefore, merely listening to their patients’ desires for the more aggressive (and expensive) treatments. No doubt in the market economy of medicine, if the first doctor does not fulfil the patient’s request for surgery, the richer patients are at liberty go and find a doctor who will.
Here, iatrogenesis comes to mind; a term used most famously by Ivan Illich in his book Medical Nemesis. Iatrogenesis refers to diseases or health conditions caused by medical intervention. For example, when a patient is older, has other health problems, and an early-stage prostate cancer diagnosis is made, why remove a slowly evolving cancer? To do so puts him through the perils of surgery, at best it leaves him temporarily incontinent and impotent, and may have a serious impact on his overall health.
‘Overtesting’, and the heavy reliance on medical tests have been blamed for iatrogenesis. However, with regards to cancer, the crux of the problem lies in the discordance between treatment practices and patient’s expectations given the pervasive cultural representations of cancer.
The advantages of modern testing and imagery mean we are more aware of what is going on in our bodies. It may be time for us to adjust our perceptions of chronic diseases, and sometimes learn to live with the conditions that previously killed us, and still do, but thankfully, less often.
Too Much Medicine Is Bad for Our Health by Allen Frances