When it comes to cancer treatments, more isn't always better.
The heat is on again in the world of cancer treatment, both
literally and figuratively.
More and more doctors are now using an extremely aggressive
procedure to treat certain colorectal and ovarian cancers called
Hipec, in which patients first undergo surgery to remove any visible
cancer, then have heated chemotherapy pumped into the abdominal
cavity for 90 minutes to kill any remaining cells.
Although it has given some patients hope, there is almost no
evidence that the treatment is more effective than traditional
chemotherapy -- besides one small trial in the Netherlands over a
decade ago that did show a benefit, but in which 8 percent of the
participants died from the procedure itself.
We shouldn't be surprised by the sudden emergence of this
therapy. Heated chemotherapy is the latest in a long list of very
toxic treatments used by well-meaning cancer doctors who have
confused doing more for patients with doing what is best for them.
History tells us that this "more is better" dictum is rarely
true.
Aggressive cancer therapy started in the late 19th century with
the radical mastectomy, which involved the removal of the breast,
along with the chest muscle below it and nearby lymph nodes, and was
championed by William S. Halsted, a surgeon at Johns Hopkins.
In the following decades, Dr. Halsted's methods became more and
more popular, particularly after World War II, when surgeons who had
performed heroic operations on European battlefields returned to
America optimistic about what could be achieved in cancer surgery.
In an attempt to eradicate all potentially dangerous cells
without the assistance of chemotherapy -- which was not yet in wide
use -- surgeons began removing even parts of the sternum and rib
cage of certain breast cancer patients in something called a super-
radical mastectomy.
If the cancer had spread into the arms, surgeons at times removed
entire shoulders (forequarter amputations). If the cancer was in the
legs, part of the pelvis was removed with the leg (hindquarter
amputations).
The most aggressive operation of all was probably the pelvic
exenteration, devised by the New York gynecologist Alexander
Brunschwig. For cancers that had spread throughout a woman's pelvis,
he removed not only her gynecological organs but also her bladder
and rectum.
The goal of these operations was straightforward: to remove as
many cancer cells as possible, which would theoretically prolong the
survival of patients and possibly even cure them.
The problem was that none of these procedures had been formally
tested in controlled clinical trials. By the 1960s, it had become
clear that they were of little or no benefit, while causing dying
cancer patients disfigurement and suffering.
Why such enthusiasm for aggressive surgery? The explanation can
be gleaned from the language surgeons used to justify their
operations. Military metaphors were ubiquitous. In 1946, Cushman
Haagensen warned his colleagues against "surgical cowardice" in the
face of the "formidable enemy" that was cancer. Jerome A. Urban, the
father of the super-radical mastectomy, was fond of saying "lesser
surgery is done by lesser surgeons."
It was not only surgeons who made these assumptions. In the late
1980s, oncologists began treating metastatic breast cancer patients
with a highly toxic and expensive regimen of so-called very-high-
dose chemotherapy, followed by bone marrow transplants.
Once again, early data proved misleading. Women who received this
treatment turned out to live no longer than those getting standard
chemotherapy, and many died from either the high doses or the side
effects of the transplants.
Cancer patients and their families, desperate for anything that
might work after exhausting all other treatment options, are also
part of the problem. But the history of cancer treatment provides a
crucial cautionary tale for both those seeking out and those
providing heated chemotherapy today.
Doing more for cancer patients has often served a cultural as
opposed to a scientific purpose, reflecting more the desire to
defeat the cancer enemy than to take care of sick patients.
Hospitals should offer heated chemotherapy -- and insurance
companies should pay for it -- only after controlled trials have
proved its effectiveness.
In the meantime, we should remember not to conflate our efforts
with our achievements.
a professor of medicine and public health at Columbia University,
is the author of "The Breast Cancer Wars: Hope, Fear and the Pursuit
of a Cure in Twentieth-Century America" and the forthcoming "One for
the Road: Drunk Driving Since 1900."
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