THE RADIOTHERAPY RAZZLE-DAZZLE
Prof Courtnay Bartholomew
Trinidad and Tobago Express

Port-of-Spain, June 24, 2009 -- I was livid, very livid when I was told that a patient from one of the Caribbean islands travelled, shall we say, "abroad" for private treatment of his cancer of the pancreas for which he had surgery. Why am I annoyed? It is because he was subjected to inappropriate and very expensive postoperative treatment with radiotherapy and chemotherapy to the tune of US$28,000, which his son had to borrow from the bank.

To be blunt, I believe that it is grossly unethical to exploit fatal illnesses at great cost to the patient, many of whom cannot afford it, especially when the doctor knows full well that the treatment is ineffective or at most prolongs life for only a short period of time, not to mention certain side effects.

Surgical resection for pancreatic cancer is the primary treatment for this disease, but it is not uncommon for surgeons to do a laparotomy (open the abdomen) on these patients only to close the wound immediately afterwards because of the inoperability of the cancer. Unfortunately, most textbooks of medicine testify that the surgical potential for "curing" patients with this serious ailment is restricted to the less than 10 per cent, who are able to undergo a complete surgical resection. Even so, the five-year survival rate following such operations is also only about nine per cent. In fact, several papers from the best centres abroad have shown that, contrary to a few others, adjuvant chemo-radiotherapy not only fails to benefit patients but may even have a deleterious effect on survival.

Now, radiation therapy is a physical form of treatment that damages any tissue in its path. Cancer cells are more sensitive to the lethal effects of radiation than normal tissues. However, while non-cancer cells can recover from this damage, cancer cells cannot. The challenge for radiation treatment-planning, therefore is, to deliver the radiation to the cancer with as little normal tissue in the field as possible. This, of course, calls for careful expertise and efficient and modern equipment.

This is not to say that radiotherapy and chemotherapy do not have a very important place for certain diseases and cancers, albeit extremely costly, but many cancers fall into the category cited above. To name just a few others, for example, the standard treatment for kidney cancers is surgery (nephrectomy) and there is no proven role for radiation therapy or adjuvant chemotherapy following successful surgical removal of the tumour. Certain bone cancers are radio-resistant as are ovarian cancers.

As for lung cancer, radiotherapy is much less effective than surgery and can only offer long-term survival in certain types of this cancer. For example, it is said that the treatment of the common small-cell carcinoma with combinations of cytotoxic drugs, sometimes in combination with radiotherapy, can only increase the median survival of patients with this highly malignant type of lung cancer from three months to over a year. In fact, the overall prognosis in lung cancer is very poor, with over 80 per cent of patients dying within a year of diagnosis. Indeed, not even John Wayne and Yul Brynner could be saved.


With respect to the oesophagus, although squamous carcinomas are radio-sensitive, radiotherapy alone is associated with a five-year survival of only five per cent. For cancer of the stomach, surgery offers the only hope of cure, which can be achieved in 90 per cent of patients with "early" gastric cancers and postoperative radiotherapy has no value whatsoever. Radiotherapy also has only a marginal effect on survival in malignant cancers of the brain in adults and cerebral metastases. So said, I hope that Senator Edward Kennedy's response to the treatment of his brain tumour will be an exception, but I am sure that he has the best of treatment strategies.

Patients' responses to the diagnosis of cancer and its implication vary from shock to denial, anxiety or depression. This calls for physicians with great maturity and tact, and doctors must remain sensitive to patients' needs and fears, yet still be able to discuss the appropriateness of starting and stopping treatment. Their relatives also need to know whether treatment has the potential to be curative. In general, it is important for patients to be informed of their diagnosis and given some idea of their prognosis so that an informed discussion can follow about treatment options, especially when extremely high costs are involved.

Indeed, since most non-surgical treatments for cancers have a narrow therapeutic index, it is not often worth risking serious and life-threatening toxicities unless cure or long-term control of the disease is possible. As our distinguished professor of medicine in Dublin taught us: "Some illnesses call for masterly inactivity." People need to know all this.

Finally, I was amazed at an advertisement in the press last week for patients to attend the Brian Lara Cancer Treatment Centre of Trinidad and Tobago. It read: "Diagnosed with Cancer? Don't wait. Get a second opinion at the (BLCTC). You do not need a referral letter." What? No referral letter needed? This is unethical and is professional anathema. As a general rule, specialists should only see patients upon referral from other doctors. Moreover, radiotherapists are not specialists in general medicine or surgery.

I have discussed this with several of my senior professional colleagues and they are likewise appalled at that advertisement. Of course, I am not going to bother to refer this to the Council of the Medical Board! However, needless to say, Brian Lara himself has nothing to do with all this, but he needs to be cautioned about how his name is being used.