As a senior oncology clinician and researcher, I was asked to write about “Oncology beyond science.” After 27 years of dealing with cancer patients, a lot of ideas swirled around in my head. Since leaving medical school and studying to be a physician specializing in cancer, all my lecturers had emphasized the importance of science in advancing medicine. During my postgraduate oncology fellowship in New York, my mentor and supervisor distilled into me the importance of basic scientific and clinical research. However, as I have progressed through my career, I have learned to listen carefully to my patients' concerns and wishes.
In Australia, over the last 25 years, the Holy Grail of Oncology has been to increase the 5-year survival rates for all neoplasms. To this end, we have achieved that much-the 5-year survival for all cancers has increased from 48% in 1990 to 65% in 2012 in Victoria, Australia.[1],[2] What an achievement! However, more and more patients are looking to natural and complementary medicines for their treatment. Medicine and the practice of oncology is an art form. We take a history, examine the patient, and order tests which confirm a diagnosis. Then, we formulate a plan based on the best available treatments science has to offer. Yes, therapy has to be based on factors as varied as your age, performance status, stage of cancer, renal and liver function, etcetera. However, that is from the doctor's perspective! Often, we forget that the real cruncher is the patient's perspective. Many a times, I have seen patients forgo the whiz-bang therapy at the tertiary referral hospital for treatment close to home. Patients just want a loved one close to them during this challenging time. That may mean going to a local hospital where their son or daughter is able to accompany them, while they have their chemotherapy, radiotherapy or even surgery.
We also have to take into account patient preference for enhanced quality of life, not necessarily length of life. We know that cancer therapies can induce significant adverse events and often patients, especially geriatric patients, would like to minimize these, even if it means that it may impact longevity. Oncologists sometimes forget this important piece of the cancer puzzle.
The “C” word is terrifying (when you hear it being spoken about you personally)! Hence, many questions go through a patient's head. Am I going to make it? How long have I got to live? Is there going to be much pain or suffering? Who will look after my children, partner, or parents? And so, the questions go on. This is where empathy and understanding come in. Establishing patient rapport and trust is a key. Artificial intelligence may be the way of the future; however, at present, computer algorithms cannot hold out a sympathetic helping hand or maintain eye contact. We want and deserve human contact.
What about if I change my diet, Doc? Will that help me to fight this cancer? In many cases, a poor diet and obesity have contributed to the development of a malignancy.[3] Patients do not need judgment, but they want a plan moving forward. Working with a dietician often helps them to eat healthier and also gain some control over their life, which is often spiraling out of control.
Is exercise helpful in coping with cancer and its treatment? Well, there is strong scientific evidence that a structured exercise program can elevate mood, decrease fatigue, and improve function in cancer patients.[4] I am a firm believer in getting my rehabilitation and exercise physiologist colleagues to help in this endeavor. The feedback from patients about exercise is always positive.
The other day, a patient brought a whole shopping bag full of bottles of medicines. Most of this was compromised of various natural remedies, herbal medicines, and vitamins. I am glad to see that research is being done into this field. A lot of natural remedies have a placebo effect of making the patient feel better.[5] Some, for instance ginger decreases the side effects of chemotherapy-induced nausea.[6] The patient feels more in control and enjoys the feeling of taking ownership of their own outcome by contributing to the fight. Occasionally, complimentary medications have serious side effects such as liver failure.[7] However, having an honest, nonjudgmental relationship with a client usually leads to one managing any adverse event successfully.
Finally, we have to realize in 2019 that science does not have all the answers. Dying with dignity is important. Sometimes, backing off on futile conventional therapies is what is required after a long and arduous battle with malignancy. Some patients have a bucket list that they would like to complete before their death. Recently, a patient of mine with advanced melanoma had done well for 9 years with conventional management but wanted to spend her last days with her family in Serbia. She had spent the last 40 years in Australia. There were many logistical hurdles to overcome, such as her bowel obstruction, but she successfully made it to Belgrade, and according to her niece, she spent a peaceful and productive last 2 weeks with family there. It was a dignified death and one that gave me satisfaction since I was able to facilitate it. Palliative care and home hospice are making a huge difference in patients' quality of life and lowering their anxiety about death and suffering.[8]
What we as physicians must realize is that there is so much more that can and should be done to help cancer patients beyond just science. There is meditation and religious faith which can bridge the gap between human suffering and the “afterlife.” Bringing hope, relieving suffering, and making patients live longer are a real privilege.
