Cancer is a perplexing opponent. Over a hundred distinctive anatomical and histological diseases are known as cancer. There are molecular variants within subtypes of malignancies of a single organ, with differing prognosis, metastatic potential and response to treatment. Its arcane nature is reflected in its complex genetic and biochemical pathways, cell survival mechanisms and processes of proliferation and dissemination. It is never a static challenge. Its inherent genetic instability, evolution and resistance undermine our immune system and the artillery of treatments available. Worldwide, the past 40 years have seen over $200billion invested into cancer research and over 1.56million research publications. These efforts have procured remarkable advances in our understanding of cellular biology and molecular genetics. The sequencing of the human genome and molecular profiling have propelled recent successes with isolated targeted therapies, and provides a strong foundation for future treatment modalities. However, for most common cancers, this has translated into, at best, modest improvements in cancer survival. At worst, perhaps treatment attempts may even be to the detriment of patient’s quality of life? The need to balance survival and quality of life is particularly pertinent to us. In Australia, cancer is one of the leading causes of mortality, and has surpassed cardiovascular disease as our greatest disease burden. Within their lifetime, 1 in 2 men and 1 in 3 women will develop cancer, with incidence rates expected to rise by 30% over the next decade as the population ages 17. Over the past 25 years, the nation’s age standardized cancer mortality rate has decreased by 16%, with fewer deaths for most common types of cancer. People with cancer are now living longer. With a greater number of cancer survivors, there is a crucial need to address issues of quality of life.
Cancer is a diagnosis embellished with fear. Conspicuous lumps, suggestive symptoms or a family history unleashes a torrent of thoughts and fears of receiving the bad news. The stigma associated with cancer once drove patients to hide their illness. With the belief that there was no cure, then perhaps it would be easier to deny its presence, at the detriment of delaying possible treatments or symptomatic relief. The public image of cancer is thankfully now one of acceptance and support, as attitudes adapt to the possibility of multiple treatment modalities. With increasing access to information and a shift from paternalism towards a shared decision-making process between patients and doctors, patients are in a greater position of ownership over the course of their treatment. Often as a terminal malady, the disease itself may yield the greatest power, but the patient still has the choice to determine how they will carry themselves and the extent to which they will battle. Higher HRQOL can be expected through greater treatment satisfaction, acceptance and clarity for their journey. Every case is considered individually, as specialists collaborate to determine the right treatment for the right patient at the right time. HRQOL has exponentially improved in advanced cancers with curative potential (germ cell cancer, SCLC, ovarian cancer, choriocarcinoma, lymphoma and AML&ALL). For most remaining cancers, gains in HRQOL are seen with stable disease and remission. HRQOL has improved even for highly aggressive opponents, such as pancreatic cancer, despite treatment not extending survival. Surgery, radiotherapy and systemic therapy are the mainstays of treatment. Surgery for malignancies has transformed over decades, and is almost unrecognizable from the desperate and borderline barbaric excisions recorded thousands of years ago. Scans and biopsies have replaced the need for extensive exploratory surgery. Technological advances, innovative surgical approaches and the neo adjuvant and adjuvant treatments have allowed for less invasive processes. Robotic surgery in urology and otolaryngology extends human abilities, providing precision and access with minimal disruption to surrounding structures. Regardless of whether a tumor can be cured or more effectively palliated with surgical resection, HRQOL improves with better aesthetic outcomes and preserved organ function. Reduced recovery time and rehabilitation have also dramatically improved surgical outcomes, and thus also HRQOL.
Chemotherapy development has always been challenged with genetic diversity and resistance so synergy between a drug and malignancy can never be predicted with absolute certainty. Furthermore, animal models were unreliable and subsequently fewer than 10% of clinically trialled drugs were approved between 1970-9030. The approved drugs, such as taxanes, anthracyclines, paclitaxel and platinum compounds were applied in assorted combinations. For the fortunate few patients, some advanced cancers were cured; for others, adjuvant therapy brought disease-free or progression free survival, with fewer negative side effects. For those who received no benefits from treatment, chemotherapy may have caused needless toxicity. The dichotomy of benefits and shortcomings of cancer treatments provides a compelling rationale for measuring HRQOL. Vivid depictions of early chemotherapy resonate with a sense of despair, as patients endured the unavoidable toxicity of vigorous therapy cycles. At times, the severity of dose limiting nausea and vomiting, neuropathy and bone marrow suppression can exceed the disease symptoms. Further, fatigue and psychosocial symptoms can be difficult to distinguish from cancer symptoms. Progress has been achieved in controlling adverse effects through the use of colony-stimulating factors and chemoprotective agents which enable higher dose regimes. Administration is safer and easier with indwelling intravenous catheters. Antiemetics, platelet and red cell transfusions and broad-spectrum antibiotics have brought some relief, but the acute and chronic effects of the drugs remain a challenge. Cancer challenges every aspect of self and identity. Survivorship centers upon enhancing the quality of life of patients and their families ‘living with, through and beyond a diagnosis of cancer. Australians are fortunate to receive among the best comprehensive cancer care in the world. Public and private health services are responding to meet the holistic needs of patients. Following treatment, long term symptoms or late onset complications may require further evaluation and management. Rehabilitation, health promotion and psychosocial care improve the quality of ongoing care. medicine is innately fixated on curing and prolonging lives. There is an aversion to death, as it seemingly signifies failure and defeat. Cecily Saunders says that “people’s determination to treat was challenged and medicine is innately fixated on curing and prolonging lives”.
In some capacity, almost all medical graduates will be involved with the care of cancer patients. Although a continually shifting field, the principles within the continuum of care will remain the same. The objectives outlined by the Cancer Council Oncology Education Committee provide a comprehensive foundation on which further knowledge can be built upon. An understanding of quality of life, its measures and impact on therapeutic ratios will equip future health professionals in making the most appropriate treatment decision. Clinical experiences are valuable learning opportunities. Students will gain an insight into a patient’s journey if they spend time with them, hear their stories, appreciate the input of multidisciplinary care and observe the interaction of patients and their doctors as they share in the hopes and anguish that accompany such a formidable illness. Interests in research, epidemiology, public health and other oncology related fields should be encouraged. The burden of cancer is far reaching. It challenges and reshapes all the domains of an individual’s quality of life. Over the 40 years of the war on cancer, progress has certainly been made. “Every era casts illness in its own image”. Perspectives are seen through the light of its current understanding. Previously viruses held the answers. Now our focus is on genetics and the interplay between immunology, gene regulation and the microenvironment. In the midst of these shifts, the one common factor is the importance of each individual battle. Perhaps it is essential to redefine the war, and emphasizes quality over cure.