Doing Nothing is the Best, Sometimes

Sthabir Dasgupta

Aclinician treating cancer has a license to use whatever method of treatment is there in vogue. He can cut a tumour out, shoot ray guns at it, or poison it with old and new chemicals. The consequences, if good enough are enjoyed and if not so good enough, are suffered by the patient. That is the sole reason why the clinicians must bear the burden of enormous responsibility. He is supposed to remember the words of Dr George Lundberg, erstwhile Editor-at-large for Medscape, a very popular journal with the clinicians that when you say cancer, you are saying a mouthful. Be very careful. Hopefully, some of our clinicians try to remember this warning.

Unfortunately, however, those clinicians may be exceptions. The culture of practicing modern medicine is such that we are happy to diagnose more and more cancer cases. This culture of misguided 'war on cancer' is such that we are prone to treat cancer patients as much aggressively as possible with the hope that we are doing good to the mankind. We tend to forget that this is a false idea based on a faulty paradigm, and so this culture has made the war a failure.Neither the incidence of cancer nor its mortality rate has reduced. Still, the culture persists with the result that not only cancer patients, many well-meaning clinicians are trapped in this oppressive system.

Cancer is a group of heterogeneous diseases. Many of them are 'indolent', some of them are 'aggressive', while still others are really 'irresistible' in nature. Everybody will agree today that it is the nature of a specific cancer that calls the tune. Over the decades of experience, it has become clear that aggressive treatment does not apply universally. While it is true that aggressive cancers may be treated with aggressive approach sometimes and to some extent, it is also true that one must learn to say, thus far and no further. Truer is the fact that such an aggressive approach is unwarranted in the indolent diseases and fruitless in the irresistible ones. This distinction in cancer care is the most vital.

Such a distinction makes us conscious about the very nature of a particular type of cancer, although it is difficult to make. Pathologists are supposed to make this distinction, but they have failed for a long time to really predict how should a specific cancer behave. Thanks to improved technology, it is only during the last couple of years they are learning to read the nature of cancerous tissue in some more detail. But then, cancer is a complex biological phenomenon and there is an existence of 'biological uncertainty principle'. This principle implies that 'THE' nature of biological complexity will never be found. We should be content with approximation of biological truth.

Therefore, despite the advent of modem technology a long-term prediction of the behaviour pattern of a specific cancer remains impossible. Even short-term predictions many a time prove to be wrong. Still, with the help of newer technology we are running around detecting 'small' cancers which have remained there in our body without causing any distress or dis-ease. We hope that those days are not far away when we shall detect smaller, almost microscopic cancers. Well, that hope is not quite baseless. Cancer however, is basically a story of 'renegade' cells. There are structural differences between them and their original form, the normal cells. Mere structure cannot prove their renegade nature.

So, such an achievement in detection of cancer is superfluous. Most of these small cancers are not bad actors. They are sometimes called 'indolento-mas'. There are others which are found incidentally, not aggressive in nature and are not supposed to cause disease in the short-term. Modem pathologists say that the risk of dying from this kind of 'tumours' is much less. The point now is what are we going to do with them, or in other words, what should be our working strategy. The present culture dictates that any cancer whatsoever needs an aggressive approach. The question is, since they are not causing any harm and are not expected to cause harm in near future, can we leave them alone?

It is true that if we treat them under the banner of 'cancer war' the 'cure rate' would be 100%, and we can jolly well celebrate our 'victories'. But we tend to forget that the outcomes would have been the same had we not treated them or even 'discovered' them at all, —100% cure from a non-disease! Modern medicine, sometimes saves life, when life is in danger. In other times, it controls diseases. So, the relevant question is, what should be its duty when certain 'abnormalities' do not harm or cause any danger and do not produce any dis-ease? This is important because in the process of achieving modern medicine's triumphs, the fundamental philosophy of medicine should not be lost.

Let us look at an example. An interesting article was published last year in a famous medical journal. The article was based on a study on 1600 men with prostate cancer, a very commonly diagnosed cancer today. But these men were absolutely without any distress or complaint and their cancers were detected by a routine 'screening' programme, e.g. estimation of serum PSA level, a common practice now-a-days. They were allocated in three groups, to receive massive surgery/ intensive radiotherapy/ or to have their cancer just watched periodically. Ten years on, just 17 out of these 1600 had died, divided almost equally between the three groups, and so, no difference in the final outcome.

But then, there is a difference that we cannot ignore, a substantial difference in terms of adverse effects for it is well known that any kind of aggressive treatment results in tremendous adverse effects. The crux of the matter here was that those who had received surgery or radiotherapy were harmed enormously while their 'cancers' did not really harm them. Such adversities were avoided in those who were only on watch periodically. Burden of experience and evidence from the 'war on cancer' along the last 50 years are tremendous on us. Thus, it is becoming more and more clear today that in certain circumstances where there is inadequate proof of benefit, 'medical activism' has no place.

There are still other instances where we diagnose some specific cancers which are not only bad actors but very 'ugly' in nature. Evidence and experience suggest that no conventional cancer treatment would be effective. They are already in distress and cancer treatment in any form would only add to their pain, distress and adversities. Of course, there are patients and their families who expect some medical miracle and there is fear of litigation of non-performance on the part of the treating doctors. But the bare fact is that the outcome of cancer treatment does not depend on treatment. Treatment is meant for palliation. The outcome unmistakably depends on the very nature of a specific cancer.

So, these are also the circumstances where patients should be exempted from the programmes of 'anti-cancer' treatment. They should better be put on supportive and symptomatic treatment. Such an approach applies to 'terminal' cancer patients also. Medical activism is necessary however, in certain other circumstances when a 'bad' cancer is diagnosed. These cancers cause harm, because they are aggressive in nature. So, one or the other aggressive approach towards them is sometimes justifiable. But there also, one is expected to be conscious and judicious, and to weigh the pros and cons, for we are not supposed to kill our patients in the name of killing cancers.

Therefore, cancers are of three kinds, 'the good, the bad and the ugly'. Based on it, it seems today that many a time a strategy of 'doing nothing' is the most rational. Doing nothing of course, does not mean that we should sit idle, blissfully ignorant about the evolution of a disease. Doing nothing is not merely doing no harm. It is not just saying, there's nothing that I can do for you; so, goodbye! On the contrary, it is an art of taking utmost care in a different manner, a strategy often harder to implement than the algorithm of conventional cancer treatment. The list of 'not-to-do' includes pointless, wickedly expensive investigations also, which do not add to the value of patient's life or well-being.

Everybody would agree that days have changed so much and so rapidly that it is difficult to stick to a benevolent strategy. Sometimes people expect miracles and act in an irrational manner because they are able to spend for that. Moreover, there are new players today: Health insurance, Litigators, Fear mongers, Slippery slope of greed and temptation, Experts and Hospital conglomerates. Plainly speaking, the humour of medical practice has disappeared or fast disappearing. The culture of medicine has changed but the human nature in the face of illness has changed little. So, the situation is difficult; but doctors are supposed to sympathetically explain to them the bare facts without exaggeration.

However, the situation is so critical that most of the time we fail. There are reasons why we fail. Financial lure (performance incentive) is not the sole reason. It seems today that we have lost our vocabulary and so we depend on procedures rather than spending time talking with the patients and their near and dear ones. We refuse to think why, when we can do so much for our patients than ever before, they are increasingly becoming unhappier. As a result, an environment of frustration is reigning amongst the doctors. Activism is one way to get rid of this. They feel, to act in some way or the other is at least better than doing nothing, for patients think that something is being done for their benefit.

What is important however, is the awareness of where and why this action comes from and what it is going to create. History is replete with episodes where some leaders decided to do "good' for the people and ended in destructive wars. Therefore, wishful thinking in cancer treatment is something that is promoted by the cancer industry, because it is just an industry, guided by its own laws of profit and loss. Doctors can ignore its call. It is true that cancer patients die despite adequate treatment, but truer is the fact that more patients live despite no treatment. This fact should never be forgotten particularly in our country where most of our patients do not have access to modern treatment at all.

That does not mean that they should better be left untreated. On the contrary, it means that treatment in any form must be directed towards alleviation of distress or symptoms. Thus, 'doing nothing' means an active surveillance, finding out those who will be actually benefited by treatment and those circumstances where treatment would be redundant. This principle can be taken as a strategy of 'cancer management', for in this way we can minimise the 'burden' of cancer treatment. This could also be regarded as a radical antithesis to the technology-driven aggressive cancer-marketing.

It is said that people are afraid of death. It would be more appropriate to say that people are afraid of horrible death. There are many ways to die: from sudden death to the procrastinated death of dementia. Death from cancer is another way, where one may bang along for a long time, going down gradually but almost determinedly. It may be relevant here to quote Richard Smith, erstwhile Editor of the British Medical Journal. As for death from cancer, he once wrote, this is, I recognise, a romantic view of dying, but it is achievable with love, morphine, and whisky. But stay away from overambitious oncologists, and let us stop wasting billions trying to cure cancer, potentially leaving us to die a much more horrible death. That is also a form of 'doing nothing', sometimes.

Frontier
Autumn Number
Vol. 50, No.12-15, Sep 24 - Oct 21, 2017