Standard of Care

Newsweek published an article a few weeks ago on the difficulties we face with regards to "curing" cancer. Importantly, it also touched on the lack of progress we've made in treating cancer. The article described a situation where a patient with lung cancer underwent a successful surgery, followed by observation, only for the cancer to recur and metastasize two years later. Though it is nearly impossible for surgery to excise all cancer cells from the body, surgery without chemo is still the standard of care for many cancers, including lung and kidney cancer. In these cases, standard of care requires a "wait and see approach" after surgery which can ultimately lead to (perhaps preventable) metastases.

For Craig, standard of care did not include chemo or radiation therapy after his initial nephrectomy. Nor did it call for more frequent and more complete body scans to detect cells that may have been festering beyond his kidney, or that had escaped through his blood supply during surgery. Though Craig's cancer was considered extremely complex and abnormal, he was released with nothing more than a plan to undergo scans every three to six months. (The chest scans were limited in scope, and were not designed to detect small formations of cell growth.) His surgeon assured Craig that he had "got it all" and that he had virtually a zero percent chance of recurrence. So sure was he that Craig would live a long and healthy life that Craig was not given a mild chemo regimen to kill possible remaining cells left after surgery.

Surgery alone is not the standard of care for all cancers. After years of research, adjuvant therapy, or surgery followed by chemo or radiation, is now standard therapy for breast cancer, colon cancer, Hodgkin's disease, and others. As the Newsweek article explains, "even in the 1970s there was clear evidence-in people-of the deadly role played by cells that break off from the original tumor: women given chemo to mop up any invisible malignant cells left behind after breast surgery survived longer without the cancer's showing up in their bones or other organs, and longer, period, than women who did not receive such "adjuvant" therapy." It goes on to say that "every study of adjuvant therapy show[ed] it works because it kills metastatic cells even when it appears the tumor is only in the breast or in the first level of lymph nodes... By the mid-1990s studies had shown similar results for colon cancer: even when surgeons said they'd "got it all," patients who received chemo lived longer and their cancer did not return for more years."

Yet despite evidence of the threat posed by metastatic cells "breaking free" and metastasizing to other parts of the body - metastatic cells are responsible for 90 percent of all cancer deaths - the way we treat cancer still lags behind. It seems not only logical, but morally responsible to offer adjuvant therapy for rare and deadly cancers, in order to kill remaining metastatic cells leftover from surgery. To rely on surgery alone is arrogant, if not negligent. If we know adjuvant therapy has been successful in breast, brain, and colon cancer, why not take the leap and assume that chemo and/or radiation after surgery would be successful in other cancers? After all, we do not fully understand how or why cancer metastasizes. Given our lack of knowledge, it seems brazen to exclude potentially lifesaving tools from our (very limited) arsenal.

Adjuvant therapy does run the risk of exposing cancer patients to potentially unnecessary adverse side-effects, but side-effects can be managed, and some patients will eventually succumb to cancer, even with adjuvant therapy. But when so much is at risk, why hedge on potentially life-saving treatments? Where is the logic in withholding chemo or radiation therapies early in the process, when there is a good chance one will have to rely on a harsher form of the same therapies later in the process, when possibilities of a "cure" are few? Even more, where is the logic in withholding "harsh" treatments for relatively healthy patients after surgery, yet providing the same treatments to "dying" patients after the immune system is compromised and the cancer has already advanced? Is this not counterintuitive if the argument is that doctors do not want to expose a patient to unnecessary chemo or radiation? Adverse symptoms can be managed. What can't be managed is death due to possibly preventable metastatic cancer.

Despite what we know, standard of care for some cancers still requires that patients wait to see if the cancer returns before introducing more systemic therapies. To this day, standard of care for kidney cancer includes surgery followed by observation. Though promising chemotherapy agents exist, they are available mostly through clinical trials, unless there is evidence of recurrence or metastases. Waiting quite possibly cost Craig his life. Failure to act is not a viable treatment option.

We are only scratching the surface of cancer. The more we research, the more we understand that cancer is aggressive, and highly adaptable. How can we be so certain about our treatment options when we still do not fully understand what it is we're fighting? If there is even the slightest possibility that chemo and radiation therapy after surgery could, at the very least, delay death, then it is worth considering. In the end, patients should have the right to choose whether to proceed with additional treatment after surgery. Unfortunately for Craig, he was never given the choice.

Then again, perhaps when it comes to kidney, lung and all the other tricky cancers, surgeons really are superhuman. -- J