HEALTH DECEMBER 27, 2013
It is more than 12 years since the writer and broadcaster John Diamond wrote his cancer diary, recording all that happened to him from diagnosis to near-end. Starting as a sceptic, with a distrust of conventional medicine and its practitioners, he went on to explore the various complementary and alternative systems and concluded with his book Snake Oil and Other Preoccupations, a skilful and often very funny exposé of those who exploit vulnerable people by offering false hope.
There have been a number of accounts in the press, notably by Philip Gould, Christopher Hitchens, Iain Banks and others, who have undergone physical and mental ordeals in receiving treatment for a terminal illness. Perhaps the most poignant message came from the poet and translator James Michie, who wrote, just before he died, I used to fancy crabmeat as a treat: Now Crab’s the epicure, and I’m the meat.
These courageous and articulate people deserve our sympathy and respect but their experiences are not typical. While suffering and death are newsworthy, the stories of the thousands who are quietly cured never reach the headlines.
At this point, I should declare my credentials. During a lifetime’s work as a surgeon in the NHS, I treated many people with cancer in various parts of the body. About 30 years ago, mid-career, I was found to have a malignant tumour; my chances of surviving for five years were less than one in 20. Following chemotherapy, radiotherapy and eventually major surgery, I made a good recovery and am lucky to be able to write these words today. The experience taught me a lot and profoundly influenced my attitude to those of my patients with similar problems.
Then, many years later, I noticed a small lump beside my nose which I recognised as a basal cell carcinoma: a tumour that, left untreated, would have spread and destroyed my whole face. A colleague removed it under local anaesthetic and I have had no trouble since. In a letter to the Times in April 2011, I suggested that the practice of including these two conditions under the same emotive label of cancer (“the Crab”) was misleading and should be abandoned.
We now know a great deal about the causation and behaviour of cancer, far more than when I started my career in medicine. From the moment of conception when the sperm meets the egg, the embryo undergoes trillions of cell divisions, controlled by the code of its inherited DNA, eventually resulting in the birth of a complete human being with unique characteristics. Growth continues into adult life but is necessarily regulated and balanced by a process known as “apoptosis”, which involves cell death. Normal cells have a limited lifespan and when they have outlived their usefulness they are knocked out. Cancer cells are different, in that they are not subject to apoptosis and, having escaped from supervision—either through a gene mutation or as a result of damage to the DNA by an aggressive chemical such as is found in tobacco smoke—they continue to multiply.
This process can be replicated in the laboratory. If you take a small sample of cells from your mouth and put them in a Petri dish with warm water and nutrients, they will continue to divide quite happily until one day you find that they have all died. In 1951, an African-American woman called Henrietta Lacks developed a growth on the cervix of her uterus. Cells cultured from her tumour did not die and, as far as I know, are dividing to this day in laboratories all over the world, providing us with a priceless means of studying the behaviour of cancerous tissues.
As cancer cells multiply in a human body, they form an expanding tumour, which compresses and damages neighbouring structures. Eventually, some of them may break off into the circulation and form colonies (metastases) in other parts of the body.
The extent to which this happens defines the degree of malignancy of the tumour.
Relatively benign lesions such as the one on my nose remain in the same place, whereas the one that I’d developed many years previously had the capacity to kill me, had it not been for the excellent treatment that I received from the NHS.
Today, not only do we understand how these diseases progress but we also have better means of combating them, whether by surgery, or radiotherapy, or drugs that block cell division. As a result, many tumours that were considered lethal in my day are now susceptible to treatment, if not curable. These include some forms of childhood leukaemia, Hodgkin’s lymphoma and the testicular cancer known as seminoma. We are making good progress with breast and bowel cancer and, to a lesser extent, with growths in the lungs and stomach.
Cancer is not a diagnosis. It is a label—and a misleading one at that, given the wide range of conditions that it covers. People labelled as cancer victims constitute a target group for hard-nosed entrepreneurs. An internet search for alternative cancer treatments leads to a huge range of products that are advertised as “natural ways in which to attack and kill your cancer”.
Note the use of the word “kill”, rather than “cure”. Most of these preparations do not claim to cure cancer because (in this country, at any rate) such a boast would be illegal.
The terms “gentle”, “natural” and “without harmful chemicals or side effects” occur frequently. These advertisements are principally aimed at the terminally ill and those who have been told by their doctor that there is nothing more to be done.
These desperate people are the ones most likely to pay for alternative therapies and it is interesting to note that though there is plenty of advice on dosage (start with three bottles a day and increase as necessary, for example), there is no mention of price. The ugly little dollar sign appears only once an order has been placed.
Dr Stanislaw Burzynski of Houston, Texas, attracts desperate people from all over the world to his multimillion-dollar cancer clinic. His methods employ a group of substances that he identified and named “antineoplastons”, which are concocted from a mixture of amino acids found in urine. Some people have experienced a remission, albeit temporary, and their cases are backed up by enthusiastic endorsements from grateful relatives. However, although there have been many requests for a controlled trial, none has ever been conducted in a form acceptable to mainstream scientists and it is impossible to know how often these treatments result in failure.
Neighbouring clinics in Houston spend much time and money in caring for Burzynski’s former patients before they finally expire. Although his methods have been repeatedly criticised in the scientific literature, there seems to be no means of stopping him pursuing these questionable activities. He would be a comical figure – a kind of Donald Duck with a stethoscope – except that the life events in which he trades are pain, tragedy and bereavement.
We need to demystify the problem. Cancer is ordinary; it is normal; it affects all of us indirectly and one in three of us will get it. To treat it as a sort of fairy-tale giant to be fought and conquered is to fuel unnecessary fear. The journalist Matt Ridley wrote in the Times in June: “Cancer fights hard. We must be bold to beat it.” Yet what we need is not boldness but patient, objective, scientific study, building theories on the known facts, testing them and rejecting those that do not work.
According to members of the US National Cancer Institute, writing in the Journal of the American Medical Association this summer, the term cancer “invokes the spectre of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime”. The group urges that the word be used to describe only “lesions with a reasonable likelihood of lethal progression if left untreated”; pre-malignant conditions should not be labelled as cancers or neoplasia, nor should the word “cancer” feature in the condition’s name, it argued.
We badly need a new expression to replace an obsolete and misleading term. I suggest “dDNA” (damaged DNA), which, after all, does reflect what is going on. When people ask their doctor the question, “Have I or have I not got cancer?” they expect a straight answer, but the question is not straight.
A response might be: “We don’t use that word any more. What we do say is that you have a dDNA problem, which includes all sorts of tumours, some of them very dangerous and others much less so. In your case, we need to do further tests and investigations, at the end of which we will be able to get together and form a plan of action to put you right.”