Cancer treatment should be carried out successfully in a comprehensive manner through the combination of several treatment modalities. Surgery, Chemotherapy and Systemic therapy jointly play a major role in present day cancer treatment and their individual values vary with the type and the stage of the disease. Primarily, the patient’s health and strength to withstand such treatment has to be considered prior to implementing any form of cancer therapy.
The doctors should know ‘when not to treat cancer’ just as much they know when and how to treat cancer. ‘No Treatment’ could be a better treatment for some patients rather than adding further toxicity and suffering.
Cancer is on the rise in Sri Lanka, with nearly 20,000 new patients diagnosed each year. Cancer treatment is not a one-time treatment. Many patients survive with it being controlled or uncontrolled, while most would require second, third or even fourth time treatment.
All cancer treating physicians and surgeons follow the standard guidelines laid down by competent international authorities to regularize treating cancer patients based on current protocols. These are set up by expert authorities considering the cost, benefit to the patient and the health authorities. Cancer patients in Sri Lanka have the benefit of obtaining treatments sometimes worth millions of rupees which are not considered appropriate due to the cost even in some highly developed countries in the west. The Government Health Service in Sri Lanka pays colossal sums against an uncertain benefit to patients. We lack the required infrastructure to practice such cancer treatment with precision as is apparent in the present evidence based treatments.
Wrong selection of radiotherapy machine or the modality: would it make the cancer patient worse?
Many patients go through radiotherapy at some stage of their cancer, and many modalities and equipment are available to deliver radiotherapy. Linear Accelerator therapy, Gamma knife therapy, Cyber knife therapy, Tomotherapy, Cobalt therapy, Brachytherapy and Radio-Isotope therapy are some. Radiotherapy has reached its highest standards today but does not attribute much to the overall cancer cure. Normal organ damage has become a minor challenge now in the present context of the new research recommendations laid down by Radiation Biologists on normal tissue tolerance levels. So that the radiotherapy modalities available today are quite sufficient to treat cancer patients without compromising their normal organs while maximizing the damage to cancer site.
It is not the radiation machine but the Radiation Oncologist’s decision to select the best modality of treatment that determines cancer cure.
Radiotherapy however would destroy cancer cells in that particular site. It is an additional treatment after the primary surgical removal of cancer. Sometimes it only offers a short term symptom relief. Most patients die of cancer dissemination to other important organs of the body such as bones, brain, lung or liver. Radiotherapy in any form would neither prevent nor cure such cancer dissemination.
Often cancer patients get into a dilemma as to what treatment would be best. The patient then becomes helpless and could easily be misguided in seeking treatment. Controversial and unethical treatments suggested by unauthorized persons could drive them to disaster.
Moreover, there is undue publicity and unwarranted requirement of high tech treatments highlighted by some outside the field of Oncology. Such campaigns only bring business gain rather than therapeutic gain. Most equipment have been bought unnecessarily without prior assessment of their requirement. Overloading radiotherapy machinery by erratic promotional marketing would not attribute to cancer cure, instead cause an additional burden with no justifiable gain.
Second or third line cancer chemotherapy involves a massive cost: benefit in terms of survival?
Chemotherapy consists thousands of anti cancer drugs, toxic to the cancer and to the patient’s normal organs. Anti cancer therapy is designed by Oncologists in a manner that would cause minimal side effects to the patient with maximal destruction to the cancer. Many conventionally designed anti cancer drugs used for years in the past have shown proven benefit in controlling cancer, while some have even brought cure. Thousands of newer molecules are being manufactured by the pharmaceutical industry which would sometimes cost millions of SLR per single patient. We should look into this aspect of unacceptable health resource drainage by purchasing new drugs at exorbitant costs and of doubtful benefit.
There are special anti-cancer drugs in addition to the conventional chemotherapeutic drugs. The Health Ministry has implemented an invaluable process called ‘Named Patient Basis Drug Provision’ through the Medical Supplies Division in association with the State Pharmaceutical Corporation. This process provides any drug requested by the oncologist at unlimited value costing millions for a single patient per year. Today there is an extra budget of SLR 15 Bn, to purchase over 40 drugs at exorbitant sums, which have a very variable efficiency score from 0 to 75%. Despite this a considerable proportion of cancers would either recur or spread.
The challenge today globally is focused on developing suitable systemic treatments via precision anti cancer drugs for individual cancer patient’s Genomic Profile. It is regarded as the only way to prevent cancer dissemination and deaths. The Sri Lanka College of Oncologists should address these issues in collaboration with the health authorities, fund raising organizations and the public, and plan a rational approach logistically before dumping in millions worth high tech equipment or drugs that are not wanted.
The answer to this waste is to practice Genomic Based Personalized Chemotherapy that has a greater strength in excluding the non- responding drugs. It gives the benefit of the most appropriate precision drug to the patient. This concept is not only confined to cancer treatment but extended to many other disciplines of medicine.
The key factor is a Validated ‘Bio-Marker’ for a particular cancer in a particular person. It is well accepted that genomic based drug prescription would extirpate the inadvertent use of these expensive molecules to reduce their waste. It would improve the efficacy of the treatment outcome while minimizing toxicity and unwanted side effects.
Most patients would helplessly agree with whatever Chemotherapy suggested by the Oncologist. They even request the Oncologist to give any drug at whatever cost to cure them. Is it worthwhile giving a drug worth millions to try to prolong a terminally ill cancer patient’s life by a few months? It would only add intolerable side effects that would deprive the patient’s last few days of quality. It is more sensible to arrange a good palliative care program, which would guarantee them the remaining lifetime with a reasonable quality without treatment induced mutilation.
The writer was the President of Sri Lanka College of Oncologists and Ex-Chairman of the Board of Study in Oncology & Radiotherapy in Sri Lanka. He is a Member of European Society of Therapeutic Radiology & Oncology and the Principal Investigator of International Clinical Trials, National Cancer Institute of Maharagama.