Regular readers will have noticed that I haven’t been blogging nearly as much as usual. All I can say is that a combination of personal and professional issues and obligations have gotten in the way. Also, I have been a bit under the weather, as hard as it is to believe that a Tarial cell-driven ultimate computer can be. Fortunately, however, things seem to be looking up, and I think that I’ll be able to get back into the swing of things next week. In the meantime, I saw a great article by oncologist Ranjana Srivastava, who notes that My patient swapped chemotherapy for essential oils. Arguing is a fool’s errand. It’s about a topic that I’ve written about a lot: What do you do when faced with a patient who is seeking alternative medicine to treat her cancer and is not interested in effective, science-based treatments.
Dr. Srivastava begins with an anecdote, one similar to what pretty much every oncologist has probably encountered at one time or another:
“Tell me why I should have your chemotherapy when I can be healed naturally!”
His face is set, his arms defensively squared. His friend carries a pamphlet that features a suspiciously healthy woman with glamorous hair and a glowing complexion. This is the urgent appointment of the day, for whom other patients were hastily shuffled to make room.
I know I shouldn’t take the bait but, like an addict, I have the urge to say:
Go ahead then, be healed. And I will almost certainly see you again, emaciated, ruined, lamenting the fact that it’s too late.
Thankfully, the code of conduct glides in. I imagine his dread. I remember my position. And I say: “Tell me more.”
I fully empathize. I don’t see such patients that often, likely not as often as Dr. Srivastava sees them, but I do see them. For a breast cancer surgeon, there are generally two kinds of such patients. One kind is the woman with early stage breast cancer who wants to treat her cancer “naturally,” without surgery, radiation, or chemotherapy. Such patients are, of course, usually in good shape. Often they are asymptomatic, their cancer having been discovered by mammography, or they have relatively small, palpable lumps in one of their breasts, the only symptom that their cancer has just yet produced. It’s understandable that such patients would be frightened at the prospect of surgery, followed in some cases by radiation therapy and chemotherapy, both of whose unpleasant side effects and complications are generally well known among the lay public. Without a knowledge of the biology of breast cancer, it’s not unreasonable to ask why such drastic treatments are needed to treat an asymptomatic disease or a little lump. On the other hand, the specter of cancer in the popular imagination is such that it terrifies people.
The second kind of patient I see like this is a woman who has neglected her breast cancer, treating it either “naturally” or not at all, so that it was allowed to grow unchecked, unremoved. This results in something known as en cuirasse disease, or, as I describe it, an ulcerating, fungating, bleeding, stinking tumor mass that can’t be resected without resecting a large portion of the chest wall. En cuirasse carcinoma is a horrible, painful, and nasty manifestation of breast cancer in which the cancer grows from the breast into overlying skin and spreads along the chest wall and back in nodules that eventually coalesce into large contiguous tumor masses. When breast cancer progresses to this point, the en cuirasse tumor often bleeds and becomes necrotic, leaving the unfortunate woman with a chest wall covered with bloody, partially dying tumor that smells like rotting meat–mainly because it is in essence rotting meat, with living tumor in and around it.
It’s a horrible fate, particularly when the cancer hasn’t spread beyond the chest wall and is the only site of disease. When that happens, there’s no acute danger of the patient dying from metastases in the short term, but the horrible local tumor can cause intense pain. (I wrote about this very phenomenon in the context of story of Michaela Jakubczyk-Eckert over 12 years ago.) Fortunately, en cuirasse disease is not always unsalvageable if it is not too extensive. Chemotherapy can often shrink the tumor masses markedly, and, if they’re confined to the breast, a mastectomy can clear the local disease. I’ve seen some pretty dramatic recoveries, as long as the chest wall disease is not so extensive as not to be resectable after chemotherapy.
But let’s get back to Dr. Srivastava’s story:
He asks: “What’s the guarantee of your chemo, anyway?”
I have perfected my retort during sleepless nights.
In life there are no guarantees but you have a curable cancer. Yes, there will be side effects but we can manage them. No, I can’t guarantee a cure, but I’d recommend evidence-based treatment any day over the magnet that purportedly draws out cancer cells. And while we are there, it’s not my chemotherapy. Your taxes fund my job but I don’t profit from giving you chemo.
But how many times have I heard that if oncologists hectored a little less and listened a little more, we might win more hearts?
So I bite my tongue again, thinking of the alarmed nurse who begged me to change his mind. As I talk him through his various options from least to most intensive, I remember the patient who swapped chemotherapy for essential oils, the one who chose to “burn” the tumour out and the one who suggested I become a sales representative for a life-saving juice.
“You don’t convince me.”
“You have the facts, you get to decide,” I reply.
I used to think that these second opinions were illuminating for patients and nudged them towards change. But what I have learnt in the last few years is that cancer patients in search of alternative cures are more deeply entrenched than ever in their beliefs.
I also note that I don’t profit by operating. I’m an academic surgeon. My pay is the same whether I do 100 or 400 cases in a year.
Be that as it may, Dr. Srivastava is correct. Arguing with such patients is pointless. Even though that is the case, that doesn’t mean that there’s nothing that can be done. I’ll admit that my perspective is limited because I am extremely specialized. I’m a surgeon, not a medical or radiation oncologist, and I generally treat only one kind of cancer, breast cancer. My goal with these patients is to persuade them at least to let me operate on them. Surgery alone can cure breast cancer, as I’ve described more times than I can remember. Surgery alone, of course, is not the ideal treatment. There’s a reason we add adjuvant therapies to surgery. Chemotherapy, radiation, and endocrine therapy can decrease the chance of recurrence, sometimes markedly. In some cases, chemotherapy alone can cure breast cancer. Still, it is surgery that is the primary modality used to treat surgery and most other solid tumors, like colon cancer.
So what to do when faced with a patient like this, someone who doesn’t want conventional treatment that can save her life?
My thought process with these patients seeking alternative cancer cures is actually simple. It has to be, and it’s this: If I can get them to agree to surgery, at least they have a fighting chance to survive, even if their chance is not as good as it could be if they were willing to accept the full gamut of science-based multimodality treatment for their cancers. I don’t care that much if such patients do what do many of them who accept surgery but refuse chemo/radiation/endocrine therapy do, which is to credit their survival to the quackery they chose and not to the surgery that actually cured them. Yes, it’s frustrating as hell to see patients like Suzanne Somers or Chris Wark undergo surgery for their cancers and then attribute their survival to whatever quackery they decide to undergo.
At least they lived.
In other words, I value saving the patient’s life with what I CAN do (surgery) if I can, or at least giving her the best chance that *I* can give her and get her to accept.If she wants to attribute her survival to the quackery that she chose in addition to surgery I persuaded her to accept, so be it. Such is life. At least she’s alive to do that.
Unfortunately, even though I’ve had some success persuading patients at least to undergo surgery, I can’t argue with Dr. Srivastava’s conclusion:
It has been received wisdom that oncologists can see off quackery through good communication but I’m afraid that isn’t so.
Oncologists have been properly entangled in a web of fake news. Their authority has been undermined and their expertise ridiculed by a determined, global and hard-to-track battalion of quacks and their acolytes. Greater vigilance, stronger regulation and improved health literacy might help, but the pull of alternative cures is strong.
Make no mistake. With so much misinformation fuelling the use of increasingly bizarre alternative therapies, patients will be ultimately robbed and disappointed, and their doctors will be relegated to the sidelines. To paraphrase an old joke, oncologists will no longer be giving chemotherapy until the grave, but the quacks will be laughing all the way to the bank.
Of course, I can’t help but note that none of this is new. I’ve been combatting quackery online for nearly 20 years now, the last 14+ years blogging and the last 9 years on Twitter. There’s nothing Dr. Srivastava describes that I haven’t been dealing with a very long time. Indeed, one thing that I (and other skeptics in medicine) often find frustrating is how many doctors act as though fake news, propaganda for quackery, and the resistance of believers in unscientific treatments to reason and science are something different now than they were in the early days of the Internet. Don’t get me wrong. I’m happy to have new doctors realize the threat of quackery, fake news about medicine, and medical pseudoscience. We need a lot more to join us. I just hope they understand the history of those who have gone before fighting this battle long before they realized the problem existed.