Five Cancer Practices That Must Stop!

Zosia Chustecka

http://www.guardian.co.uk/

How doctors choose to die
When faced with a terminal illness, medical professionals, who know the limits of modern medicine, often opt out of life-prolonging treatment. An American doctor explains why the best death can be the least medicated – and the art of dying peacefully, at home

guardian.co.uk, Wednesday 8 February 2012 20.00 GMT

‘Doctors know enough about death to know what all people fear most: dying in pain, and dying alone.’

Years ago, Charlie, a highly respected orthopaedist and a mentor of mine, found a lump in his stomach. He asked a surgeon to explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds – from five per cent to 15% – albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with his family and feeling as good as possible. Several months later, he died at home. He received no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen – that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will be cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the intensive care unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly: “Promise me that if you find me like this you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this – that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to hospital. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable”. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.
That scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. But, of course, doctors play an enabling role here, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the A&E ward with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was a lawyer from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical centre in which all this had occurred, she died.
It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are victims of a larger system that encourages excessive treatment. Many doctors are fearful of litigation and do whatever they’re asked to avoid getting in trouble. Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and was admitted to A&E unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.
Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 (£314,500) bill. It’s no wonder many doctors err on the side of over-treatment.
But doctors still don’t over-treat themselves. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures.
Several years ago, my older cousin Torch (born at home by the light of a flashlight) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.
We spent the next eight months having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sport nut, and he was very happy to watch sport and eat my cooking. He even gained a bit of weight, eating his favourite foods rather than hospital food. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state-of-the-art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. There will be no heroics, and I will go gentle into that good night.
• Ken Murray, MD, is clinical assistant professor of family medicine at USC.

Comment from Linda Greeff, Director PLWC

This is an interesting article to review when faced making treatment decisions .

It is often difficult to decide when to stop active cancer treatment , when the cure of the cancer is not possible any more.

It is imperative that patients and family members talk about the way in which they would like to deal with the end of life care . Open and conscious decision making is needed re the current treatment impact on the patient and family life and especially on the quality of life .

It is so important to remember that even when active treatment stops, it does not mean there is nothing that can be done any more for the patient. The fact is that palliative care is a specialised area of medicine that can really add quality of life to the end of life care of a person living with a life threatening disease .

It is often our own fears and lack of open communication with our healthcare teams that lead to unnecessary prolonging of suffering in the terminal phase of the illness.

PLWC would like to encourage our patients and families to live one day at a time but to always remain patient active and empowered to ask what you need to know and to make decisions re your treatment and management in a manner that will meet your own and family needs, even at the end of life .

This journey is challenging and hard but could be a very special experience if dealt with in a manner that is inclusive and open thus leaving no unfinished business at the end of life but really special memories of a life lived to the full .

May you be inspired to do just that and be brave enough to speak about the unspeakable.

Linda Greeff

Director PLWC

Smoking tobacco, using a hubbly bubbly pipe and smoking dagga (marijuana), puts young people at high risk of developing oral- and oro-pharyngeal cancers. This message was highlighted by the South African Dental Association (SADA) at a press briefing in Cape Town this week.

In the past, these types of cancer mostly occurred in adults over the age of 45, but in recent years, it has become increasingly prevalent in younger people between 20 and 30 years of age.

“While part of the explanation of this can be attributed to the Human Papilloma Virus (HPV) and the changing sexual behaviours of a younger generation where multiple partners and oral sex feature strongly, many other lifestyle practices also become significant in view of recent research results that indicate causal links between oral- and oro-pharyngeal cancer and cannabis and hubbly bubbly pipe smoking,” Maretha Smit, Chief Executive Officer of SADA said in a statement.

Cancer-causing HPV is transmitted through skin-to-skin contact, usually during sexual contact. The same type of HPV that causes cervical cancer is responsible for some oral and oro-pharyngeal cancers, and are transmitted to this region of the body through oral sex.

Link between dagga and cancer

Dagga has the same risk as any smoking tobacco in that it contains carcinogens that may cause cancer. In addition, research has also identified a link between dagga-use and HPV-related oral cancers.

Professor André van Zyl from the University of Pretoria explained that, other than regular tobacco smoke, dagga modifies the immune system, thereby causing HPV to spread easier during oral sex. Once it has spread, the cannabinoids will also promote the persistence of the HPV infection, as well as promoting tumour formation by suppressing those parts of the immune system required to protect against cancer.

In comparison to non-smokers it was found that dagga users had a more than four-fold increased risk of developing HPV-positive cancer.

“In South Africa, the use of cannabis among school-going children is on the increase. Coupled with changing sexual behaviours in the same groups and where oral sex features prominently, these trends will most like lead to increases in HPV oro-pharyngeal cancers in the next 10 to 20 years,” said Van Zyl.

Water pipe not innocent fun

Water-pipe smoking, locally known as the Hubbly Bubbly or Hookah pipe, is growing in popularity among school-going children and young people worldwide. Often with the full knowledge and approval of their parents who believe it to be innocent fun.

But that is not the case at all—water-pipe smoking is just as addictive, and even more dangerous than cigarette smoking. According to Van Zyl, the idea that the water in the Hubbly Bubbly filters out harmful substances is untrue, and smoke from the water pipe contains nicotine, tar and heavy metals and exposes the user to high levels of carbon monoxide.

What makes the water pipe even more dangerous is that the cooling effect from the water, combined with the fruity flavours of the tobacco, creates a soothing effect allowing smokers to inhale the smoke more deeply than regular tobacco smoke. The water pipe is also smoked in sessions of up to 45 minutes, therefore exposing the smoker to a lot more carbon monoxide than cigarette smoke. “Participants may inhale as much as the equivalent of 100 cigarettes,” said Van Zyl.

“The bottom-line message is that water-pipe smoking can deliver carcinogenic substances directly into the mouth and upper respiratory tract as well as the lungs,” said Van Zyl. “At the very least it is as dangerous as cigarette smoking while a further worrying aspect of the water pipe is that it exposes young people to the habit of smoking, increasing the risk of addiction. Also, because it is happening under the critical age of 16, these individuals are at enormous increased risk to suffer various cancers under the age of 45 years.”

There is the additional danger that the sharing of mouthpieces may spread other infectious agents such as herpes, hepatitis and tuberculosis.

Cancers associated with HPV, dagga and hubbly bubbly pipe smoking occurs mostly in young adults. “These young people could never imagine that they might develop oral cancer, and, it is therefore imperative that regular dental check-ups are conducted to ensure an early diagnosis of cancer in either the oral cavity or in the oro-pharyngeal area,” Van Zyl concluded.

Source: South African Dental Association (http://www.sada.co.za)

A substantial number of lung and colorectal cancer patients continue to smoke after being diagnosed with cancer, according to a new report published in CANCER.

The study provides valuable information on which cancer patients may need help to quit smoking.

According the study continuing smoking after a cancer diagnosis can negatively affect a patient’s response to treatment and possible recovery, and can ultimately raise their chance of death.

The study, led by Dr Elyse Park from Harvard Medical School in the United States, looked to see how many patients quit smoking around the time of their cancer diagnosis, and which smokers were most likely to quit. The researchers determined smoking rates around the time of diagnosis and five months after diagnosis in 5338 lung and colorectal cancer patients. Colorectal cancer, commonly known as bowel cancer, is a cancer from uncontrolled cell growth in the colon, rectum, or appendix.

Substantial group

The research found that a substantial group of cancer patients continue to smoke. At the time of diagnosis, 39% of lung cancer patients and 14% of colorectal cancer patients were smoking. Five months later, 14% of lung cancer patients and 9% of colorectal cancer patients were still smoking. And although lung cancer patients generally have higher smoking rates, colorectal cancer patients were less likely to quit smoking after diagnosis.

Other shared characteristics between patients, apart from their types of cancer, were also identified to help physicians pinpoint the type of individuals more likely to continue smoking after diagnosis.

“These findings can help cancer clinicians identify patients who are at risk for smoking and guide tobacco counselling treatment development for cancer patients,” Dr Park said in a EurekAlert! report.

Source: EurekAlert!

The study was published in the American Cancer Society’s current issue of CANCER by researchers at Moffitt Cancer Center.

Please read it at http://www.medicaldaily.com/news/20111206/8114/breast-cancer-chemotherapy-study-fatigue-women-treatment-cancer.htm

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’Healthy for the Holidays’– 10 tips for cancer survivors.

Surviving the holidays with one’s waistline, bank account and sanity intact can be challenging for everyone, but the season affords specific pitfalls – and opportunities – for cancer survivors who are mindful of staying healthy throughout the season and beyond.

One in 20 adults in the U.S. is a cancer survivor, and the number of survivors is growing, many of whom have long-term health needs resulting from the disease and its treatment.

Karen Syrjala, Ph.D., co-director of the Fred Hutchinson Cancer Research Center Survivorship Program, offers these tips for survivors. Most of them apply to anyone who wants a healthier holiday and less-stressful new year.

•  Know your holiday stress points. Do certain family members put you on edge? Do you take on too much and then find you don’t have time for it all? Start by asking yourself what makes you feel most pressured or irritable, and then what choices do you have to make this stress more manageable?  If you have to see a difficult relative, can you arrange something fun afterward? This way you can remind yourself that in a few hours you’ll be doing something that you enjoy.  It will help you get through a potentially difficult time.
•  Are there holiday events or traditions you could live without? Can you gracefully bow out of gatherings or obligations you no longer enjoy? Do you really need to bake all those cookies? Can this be the year you send a Christmas email or a link to your Facebook page instead of all those cards?
•  Are there non-holiday events you could postpone for a week or two? If your holiday to-do list is longer than Santa’s, perhaps schedule your next routine CT scan or mammogram after the holidays.
•  Remember your precious people. Schedule “together time” with those who may need you the most this holiday season, or those you most want to see. By scheduling ahead you can make sure you make time for what matters most to you. Our bodies and brains respond positively in lots of ways to time spent connecting with those we are close to; consider this important for your health during the holidays.
•  Keep moving. Physical activity is the clearest step you can take to benefit your health during the holidays and any time of year. It is certain to make you feel good and help your body and brain to function better. It can even reduce your cancer-related risks. Make opportunities to walk or take stairs for at least 10 minutes at a time. If exercising alone is hard, check with your local Y to see if they have a program for cancer survivors.
•  Practice healthy nutrition. Know what foods help you feel and do your best, then focus more on giving your body what it needs (such as fruits and vegetables) and less on trying not to eat certain foods. Eat sweets in moderation and make sure you also get protein, fiber and healthful fats. Eat your healthy food before going to a party so that it is easier to indulge in moderation. Make an appointment with a nutritionist if you are unsure what is healthy for you or if you have digestion problems.
•  Know how alcohol affects your health. Alcohol use has been associated with an increased risk of certain cancers. If you drink, do so in moderation (one drink a day for women and two for men).  Before a social event, plan ahead what and how much you’ll drink. Alternate between alcoholic and non-alcoholic drinks, such as sparkling water with lime, to help pace yourself and stay hydrated. If it’s hard to say no once you’ve started drinking, then plan to stick with non-alcoholic drinks.
•  Relax your body and mind. When you are more relaxed you sometimes get more done – and feel better doing it. When you feel wound up or overwhelmed, take five minutes to breathe deeply and scan your body from head to toe. Close your eyes and breathe in through your nose to a count of four, hold your breath for a count of two, breathe out through your mouth for a count of four, and repeat. Check your forehead, jaw and tongue for tightness, relax; then check your neck and shoulders, stretch and move them to find a comfortable position, then continue with your arms, chest, abdomen and legs. You can even breathe and relax your body while driving – just don’t close your eyes!
•  Tend to your body’s needs. Notice if there are parts of your body that aren’t working well. Make a list and an appointment with your doctor for after the holidays. Talk with your doctor if you have fatigue that hasn’t improved with time; mental fog that makes it hard to work or remember things; neuropathy (numbness or pain in your feet, hands or elsewhere), incontinence or other problems that affect your quality of life. Knowing you have a plan for attending to these problems can ease your mind during the holidays and let you focus on other things.
•  Have a long-term plan for your survivorship care. Schedule an appointment to go over your survivorship needs if you aren’t sure about your risks for long-term problems or you aren’t sure what symptoms to watch for to maintain your health. Tap into a survivorship program to help you detail a follow-up care plan to share with your primary care provider. Make appointments now so you can forget about them during the holidays.

In the Northwest region, visit the website of the Fred Hutchinson Cancer Research Center Survivorship Program at www.fhcrc.org/survivorship. For information on other LIVESTRONG Survivorship Programs of Excellence visit www.livestrong.org/What-We-Do.

But the Macmillan Cancer Support data highlights a “woeful” lack of progress for some types of the disease, such as lung and stomach cancer.

To read more about this interesting study, go to  http://www.bbc.co.uk/news/health-15726810

Cancer survivors of both genders and any age will face a variety of challenges to their health long after their initial cancer diagnosis and treatment. Vigilant post-cancer follow-up care is very important to address these challenges for the most successful outcome.

“Follow-up care and long-term management of the challenges that can arise following treatment of a primary cancer are important subjects for survivors,” explains Dr. Jui-Lien “Lillian” Chou, Radiation Oncologist and breast cancer survivor. “In addition to the health issues that arise from the treatment for the primary cancer, there is the fear of local cancer recurrence and/or the spread of cancer to other areas of the body.”

When Cancer Spreads

Cancer that has developed in one area of the body can spread or metastasize beyond that site and invade other parts of the body. Cancer cells can travel through the blood stream or lymph system; and while cancer can travel to any part of the body, the bones, lungs and liver are the most common sites for cancer to metastasize. Certain cancers, including breast cancer and prostate cancer, can spawn a distant metastasis 10, 20 or even 30 years after the initial cancer treatment.

“In general, distant or systemic metastases are considered stage IV,” explains Dr. Chou. “Once cancer has spread to several places in the body it can rarely be cured, but it can often be treated. Thanks to modern diagnostic procedures and treatment options, we have the ability to locate and manage metastases. With proper management, patients who respond to therapy can feel better and live longer.”

Bone Metastases

Bones are a common place for spreading cancer cells to settle in and start growing. These bone metastases can happen anywhere in the body, but they are mostly found in the spine, pelvis, ribs and skull.

When cancer spreads to the bone, cancer cells can affect bones in two ways, explains Dr. Chou. Cancer cells often make substances that damage the bones and leave them weak and vulnerable to fracture. In other cases, cancer cells cause bones to become harder. Both types of bone metastases can cause pain. If the bone metastasis is on the spine, it can press on the spinal cord, causing nerve damage, pain, and in extreme cases paralysis.

“Pain or a bone fracture which is unrelated to trauma (like a fall) is often the first flag for the patient and the physician. High levels of calcium in the blood can also be a sign of a bone metastasis,” says Dr. Chou. “The actual symptoms will vary according to the location and the size of the metastasis.”

Sometimes bone metastases are found before they have a chance to cause any symptoms. Cancer survivors may have tests like bone scans or PET/CT to see how far the cancer has spread. This may be done before, during, and after treatment.

Treatment Options

If you or your loved one is a cancer survivor, it is important to report any new symptoms or changes in old symptoms to the doctor right away. Finding and treating these symptoms early can help reduce the chances of more problems later on.

There are a variety of treatment options available for bone metastases, including chemotherapy, anti-hormonal therapy, radiation therapy, and in certain restrictive cases, surgery.

“Each patient must remember that his or her body is unique, and so is his or her cancer. No one can predict how an individual patient’s cancer will respond to treatment,” says Dr. Chou. “Statistics can paint an overall picture, but each individual patient has unique strengths and emotional and spiritual supports which impact how they cope with cancer. Our staff understands that and presents a range of options for the best management plan to suit the patient’s needs and desires.”

Comprehensive Cancer Care

Lubbock Cancer Center provides comprehensive care for screening, diagnosing, evaluating, and treating all types of cancer. In concert with the area’s best medical specialists, Lubbock Cancer Center can answer the need for comprehensive cancer care, from assessment and early detection through treatment and follow-up care.

Three world-class facilities – Lubbock Imaging Center, Wellness Lubbock and Lubbock Cancer Center – come together as a team of medical professionals to bring patients the latest technology and treatment options for all types of adult cancers.

For more information, please contact Lubbock Cancer Center at (806) 793-1406.

Are you or a loved one coping with side effects from cancer treatments? You’ll find reliable information and helpful resources in our side effects section of our website.

Listen to our podcasts:

• Understanding and Managing Chemotherapy Side Effects
• Chemobrain: The Impact of Cancer Treatments on Memory, Thinking and Attention
• Controlling Cancer Pain: What You Need to Know to Get Relief
• Understanding Peripheral Neuropathy

Read our publications:

Controlling Cancer Pain: What You Need to Know to Get Relief

Understanding Peripheral Neuropathy