Concerning the state of chemotherapy today, oncologists Albert Deisseroth and Vincent DeVita48 of the Yale School of Medicine have commented that the most important findings of the last 30 years have been that drugs could cure some forms of cancer--namely leukemias, Iymphomas, and some epithelial cancers. They call it both perplexing and disappointing that 90% of all drug cures occur in only 10% of cancer types. Although it was first thought that cancer cells grow more quickly than do normal cells, this has turned out not to be the case. Instead, cancer is caused by a failure on the part of the cell: instead of deciding to divide, it should, for the sake of the organism, choose to be dormant.48
Molecular biology, trumpeted by some as the next great frontier of hope, examines the metabolic pathways that constitute the biochemical basis of all life. Molecular answers are being ardently pursued in order to solve the riddle of why cancer occurs. Life is dependent on proteins, which are themselves a string of amino acids. One focus of this biochemical inquest is upon the regulatory proteins responsible for cell division. This is because cancer is understood as the proliferation of cells without restriction. Somehow the proper regulatory mechanism has been disabled when cells are replicating wildly. It is believed that the coding of the DNA determines the composition of amino acids, which in turn shapes the protein in any given tissue. This DNA is the repository of the genetic code of the organism--that which is passed on to propagate the species and prescribes who someone is structurally and functionally. Part of the DNA is wound tightly and part is unwound. When certain proteins become inappropriately unwound, it is thought to produce uncontrolled cell division. The expectation is that manipulation of these proteins may produce a shut-off valve for the carcinogenic process.
It is remarkable that for all our progress in medicine, a JAMA article49 from 1895 reads as though it were from a current journal describing contemporary practice:
[T]he widespread and increasing prevalence of cancer of the breast, its painful and terrifying features, and, above all, the very great attendant mortality, render it one of the most important of surgical conditions and one in which the most strenuous effort should be made to cure.... Operations for cancer of the breast are designed to be curative or are merely palliative, and it is needless to say that the end in view is determined by the extent of the neoplasm.... [M]ammary cancer is a curable disease, and ... the keynote to its successful management is to be found in the earliest possible diagnosis, prompt and wide excision and careful observation of the patient during the remainder of her life.
How problems are framed determines which solutions are delivered. In answer to the question, "How can local recurrence be eliminated?" one course of therapy--mastectomy--is mandated. If one asks, instead, "What is the least invasive therapy, will do the least harm, and provide equivalent survival advantage?" another intervention is pursued--lumpectomy. If the question is "What environmental, dietary, hormonal, or genetic factors, if any, contribute to the disease or its amelioration?" this launches the investigator onto other trajectories, such as chemical pollutants that are carcinogenic (some because they mimic estrogens in the body), or fatty diets that appear to increase risk, or genetic predispositions. And if a breast cancer is classified according to its growth rate or the type of cells present, this leads in still another direction--one that does not treat all breast cancers equally, classifying them by many different criteria. Patients have the right of treatment choice, but most women are so poorly informed that they cannot choose wisely.
Personal Story as Metaphor: Medicine as Savior or Slayer
I grew up listening to my father talk about work around the dinner table. Invariably in the middle of a bite of mashed potatoes and green beans, he was summoned to the emergency room to repair the fractured femur and lacerated calves of a teenager whose Harley had slid in the sand. At 10, squeezed onto the end of a bench next to a mammoth high school athlete, I'd watch my father trot onto a muddy New England football field, crunchy with frost, his trench coat flapping behind him like wings One evening after chocolate pudding, eyes shining with zeal, he described new surgical staples that made it possible for him to close bowel resections twice as fast. Often he worked tirelessly into the night while we were asleep. Although usually an energetic optimist, sometimes he'd surprise me with grouchy, venomous criticism. Later, my mother would whisper discreetly that it wasn't me--that my father had a patient sick with pancreatic cancer and he was desolate because there was nothing he could do. I observed first-hand his distaste for powerlessness in the face of irremediable disease.
Although completely devoted to the practice of his craft, my father was a reluctant patient. At 69, he needed to have cataracts removed but stalled for several years, eventually trading the benefits of improved night vision for his diffidence. Opening his closet door, he was amazed to find that all his suits weren't the monotone grey he had perceived before the surgery. It was awesome to me that after spending his life wielding the scalpel, he was so wary of it himself.
Some of his cautious hesitation was transmitted to me. When our son was born 22 years ago, with two gaping holes in a distended heart, we deliberated ambivalently about the cardiologist's urgent plea to go forward with open-heart surgery. Without it his life would have been severely compromised; with it he had a fifty-fifty chance of surviving the surgery. Now the Dacron patches stitched carefully in place by Paul Ebert when our son was 8 months old have enabled him, like the normal kids I envied when he was small, to attend college.
Two years ago I urged my niece, Sherifa Edoga, just after she had graduated with double honors from Stanford, to seek counsel from my son's cardiologist. She was born without a pulmonary artery, the vessel that carries blood from the heart to the lungs to receive oxygen. Always breathless, her lips and fingernails were permanently stained the color of blackberries, a sign of hypoxia--not enough oxygen in the blood. For anyone else it would be a 2-minute jaunt to the car, but she moved like a snail and for her the trip took 20 minutes. It was with trepidation that Sherifa decided to undergo surgery; she had had two operations as a child that had failed. But the able surgeon felt he could help. In the days before, Sherifa made great gains in quieting her fear. She died 5 days after the operation.
My father always characterizes medicine as an evaluation of the lesser of evils, requiring a cost-benefit analysis accompanied by a willingness to gamble. His awareness of doctor-induced problems (iatrogenesis) led us to be apprehensive about both drugs and procedures. Medicine can mean miracles. It can do harm. Doctors want to ply their trade to the task of genuinely serving, and patients yearn to be saved. Ultimately it is we, not our doctors, who must navigate our vessel. It is our destiny that lies on the shore.
Living With Disease
In 1995, eight million new cases of breast cancer and 3 million deaths were recorded worldwide, Breast cancer is the most common form of cancer in women in the United States, the leading cause of cancer death for black women, and the second leading cause of cancer death for women aged 35 to 54 years. Eighty percent of women diagnosed with it are over the age of 50. More than 70% of cases occur in women without any identifiable risk factors. More than 1.6 million women diagnosed with breast
cancer are alive in America today, and the 5-year survival rate is over 90% (written communication with National Alliance of Breast Cancer Organizations, March 1996). We are always looking toward future progress, toward what's new that will miraculously transform our capacities for medical management. By looking backward as well as forward, we gain insight, if not the ever-elusive cure.
Poet Lucille Cliftons50 writes:
Halsted Holman, professor emeritus at the Stanford School of Medicine, is the son of Emile Holman, who, like Cushing, was I a protege of both Osler and Halsted. Named after his father's mentor, Halsted Holman oddly echoes Virchow's social perspecfive, bringing dialogue full circle. In the middle of the 19th century, Virchow claimed that many maladies were the result of aninequitable distribution of social and economic resources, advocating that doctors should exercise their power to abolish the social conditions that are at the root of so many diseases.
Virchow asserted that "physicians are the natural attorneys of the poor."11(p316) Similarly, Halsted Holmans51 comments:
we are running
time is clocking us
from the edge like an only
our mothers stream before us,
cradling their breasts in their
oh pray that what we want
is worth this running,
pray that what we're running
is what we want.
Longevity has changed little, and the major illnesses such as malignancy and cardiovascular disease remain unimpeded. Illnesses disproportionately affect the poor, major environmental and occupational causes of illnesses receive little attention and less action, and malpractice charges intensify. Clearly, there is a crisis in health care, both in its effect upon health and in its cost. Simultaneously, medical institutions characterize themselves as excellent. Some medical outcomes are inadequate not because appropriate technicalinterventions are lacking, but because our conceptual thinking is inadequate.
Medicine cannot capitulate to less than a thorough and on-going review of its own habits of mind, as well as its practices. On the disappointing results in the treatment of breast cancer, one of Virchow's pronouncements spoken in 1896 is still germane: "Indeed, a great deal of industrious work is being done and the microscope is extensively used, but someone should have another bright idea."14(p107) Psychologist CG Jung52 commented that "[tlhe serious problems in life ... are never fully solved. If ever they should appear to be so it is a sure sign that something has been lost. The meaning and purpose of a problem seems to lie not in its solution but in our working at it incessantly."
Although breast cancer is always undesirable and bad, the women who have it are often splendid and good. No one chooses breast cancer as a teacher, but it becomes one. Many women struggling with breast cancer are heroic, powerful, and courageous. How each woman chooses to interact with this disease is as varied as the lives they live. Libby was diagnosed 3 years ago and underwent a modified mastectomy and intensive chemotherapy for a year, which eliminated metastatic liver tumors from view on a CAT scan. The tumors recently recurred. Shirley was told, after 3 years of therapy, that she had only 6 months to live without a bone marrow transplant. She decided not to follow this path, went into remission, and was alive 4 years later. Catherine found a lump while lathering in the shower, had a lumpectomy, and elected not to have her lymph nodes dissected nor undergo radiation or chemotherapy, instead exploring alternative therapies including herbs, a careful diet, yoga, and other activities that gave her pleasure. It is now 5 years that she is alive, though she has evidence of local masses. Erica did not survive a bone marrow transplant. Marilyn did. Breast cancer may be lethal, but we know birth to be an absolutely fatal disease. Many women who are diagnosed with breast cancer will die of other causes, even though they do not get over the disease as if it were a winter cold.
Debra's acupuncturist, reflecting on her breast cancer, commented, "You're the sky and the disease is a cloud in the sky." He is aware of the dualistic perspectives that sometimes have difficulty meeting: attention to the disease mechanism versus regard for the person who has it. Put simply, in one model the doctor is a mechanic fixing a broken body machine, and in the other the doctor is a gardener cultivating a healthy ecology in which the rich soil houses microbes that can combat pests. This is another debate that has echoed through centuries. In mid-19th-century France, Louis Pasteur introduced the idea that disease was located outside the body, in the form of germs. This distracted medicine, encouraging people to think that the invaders could be slain like marauders in a castle. Pasteur's contemporary Claude Bernard had insisted that it was the milieu interieur--the state of the organism; the relationship between the seed and the soil, the pathogen and its host--that was determinant. Breast conserving pioneer and physician Vera Peters53 comments that "[t]he important influence of the patient's potential to control her own disease cannot be overlooked. Probably a superior immune mechanism is the major factor allowing the majority to postpone metastatic disease for many years. Their immune potential is reflected by their state of physical and mental health, and by the lymphocyte count."