When Fighting Cancer Isn't Worth It

The most aggressive treatments currently available don't guarantee success, and they aren't right for everyone.

Jim Bourg/Reuters

The war on cancer is a civil war. It is a battle of two armies, cancer and therapy, fighting it out within a common space. It is an unfair fight.

A recent article in the Washington Post describes a controversial surgery devised by a pioneering and big-thinking surgeon, Paul Sugarbaker. This surgical procedure, known as cytoreduction and heated intraperitoneal chemotherapy (HIPEC), removes metastatic cancer before bathing the abdominal cavity in heated chemotherapy. There are many who celebrate it as life-saving, some who loathe it as toxic, and others who debate its merits and shortcomings endlessly.

The approach may be right for some particular tumors (e.g. pseudomyxoma peritonii), but is certainly wrong for others, and remains untested in still others (stomach, colon). The greatest advance seen in this procedure is the reduction in complication rates and the better selection of appropriate patients. Still, one percent of those treated die during or shortly after the operation, and about 12 percent experience serious post-operative problems. The greatest failures that accompany this procedure remain the lack of scientifically sound proof of effectiveness, as well as the perceived lack of alternative treatment for the patient.

HIPEC surgery is complex and arduous, often lasting 12 hours or more. Given the intensity of the procedure and the likely need to travel to one of the 27 states that boast of an expert, those who pursue such treatment tend to be highly motivated, younger, healthier, and wealthier. These patients also tend to use the militaristic lexicon that often accompanies a cancer diagnosis -- "fighting a war,""winning a battle,""not giving up." Dr. Sugarbaker is their ally in that war.

My job is to arm patients with the information they need so they make a thoughtful decision and move forward with no regrets.

In more than a decade of treating patients with gastrointestinal tumors, I have had more than a dozen proceed with this approach and another handful who wished to but were turned down by surgeons. Did these patients who received HIPEC benefit from this surgery? No one has been cured, some may have lived longer than they would have without it, and some undoubtedly suffered as a result. Over these 10 years, there have been advances in chemotherapy that have allowed patients longer lives, as hoped for with this surgery.

Unfortunately, in the war on cancer, a chance at a cure is the only acceptable option for most. Simply living longer doesn't cut it.

The scientific merit of HIPEC has been discussed and debated eloquently by others. When I speak with patients considering this surgery, I encourage them to identify their goals and consider their definition of an acceptable outcome. These are motivated people who desperately want to be well again, and they see the chance of a cure in their sights. I ask them what they have heard from their surgeon, and many say things like "He thinks he can get it all," or echo the hollow statistical report: "There's a 50 percent chance." To which I always reply, "Chance of what?"

The reality is that the majority of these patients will not be cured and will continue living with cancer. In the best of cases, when that cancer returns, devastating disappointment ensues. Still, most patients resume chemotherapy just as before, with no regrets for having gone through this surgery. In the worst of cases, patients never recover, experience continued wasting, suffer bowel obstructions, and endure misery for the remainder of their lives.

Presented by

Mary Mulcahy

Mary F. Mulcahy, MD, is an associate professor in the Department of Hematology/Oncology at Northwestern University, where she is part of the Public Voices Fellowship for the OpEd Project. She is the co-founder of Life Matters Media.

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