Chapter Five


Choice in Conventional Cancer Therapies

Chapter Five

American Cultures of Conventional Cancer Therapy

The most obvious divisions within American conventional cancer therapies are the differences in views between surgeons, radiation therapists, and oncologists (who provide chemotherapies, hormonal therapies, and related therapies). Historically, great battles have been waged in medical practice and in the medical journals between these three professional groups in regard to the relative efficacy of the treatments each offers for cancer. For example, surgeons committed to the use of radical mastectomy for breast cancer were skeptical of the benefits of lumpectomy combined with radiation therapy. The surgeons were equally skeptical of using nonsurgical approaches to prostate cancer.

These battles involve not only a very human economic conflict between these specialties for control of cancer treatment fees, but also reflect the strong tendency of almost every specialty to believe in the benefits of its own skills and instruments in contrast to those of other specialties. The debate among the armed services as to the relative merits of the Army, Air Force, and Navy is an obvious parallel.

What this means for cancer patients is simple but fundamental: If the first person you see about your cancer is a surgeon and he recommends immediate surgery, you may want additional opinions not only from other surgeons but also from oncologists and radiation therapists. This comparative approach is entirely obvious to physicians and others familiar with the reality of divergent medical cultures, but it is rarely spelled out to patients who want to obtain a second or third opinion.

Aggressive versus Conservative Treatment

In all three disciplines–surgery, oncology, and radiation therapy–doctors vary in their predisposition to aggressive or conservative approaches to treatment. An aggressive oncologist faced with a metastatic breast cancer in a young woman may, for example, be inclined to recommend autologous bone marrow transplant in combination with very high-dose chemotherapy and radiation therapy. In this procedure, the patient is given a lethal dose of chemotherapy and radiation and then a combination of increasingly effective “rescue” therapies that include replacing the bone marrow destroyed by the treatment with a store harvested from the patient in advance of the therapy.

This therapy is tremendously difficult, painful, and expensive, and is not reimbursed by most insurance plans. Further, as I write in 1993, no clear evidence yet exists that this protocol has demonstrated benefit in breast cancer treatment, although there is evidence of its benefits for Hodgkin’s disease and other lymphomas. Nonetheless, aggressive oncologists who believe in pushing the frontiers of aggressive treatments to the very limits of human tolerance present this protocol to many women with metastatic breast cancer as their “only hope.”

Conservative oncologists–such as Craig Henderson, M.D., at the University of California, San Francisco School of Medicine–are inclined against such aggressive recommendations when there is no clear evidence of their benefit. Henderson fought a similar battle in recent years when the National Cancer Institute issued a special bulletin recommending chemotherapy for all women with primary breast cancer, even for those with no positive nodes. Henderson and many other oncologists with a conservative clinical orientation believed that the evidence was not sufficient to justify this recommendation.

Similar stories can be told of differences between aggressive and conservative surgeons and between aggressive and conservative radiation therapists. Each specialty naturally believes in its own professional skills and tools, but within each specialty there are those who wield them cautiously and those who wield them more aggressively.

Rachel Naomi Remen, M.D., speaks of these differences in aggressive or conservative approaches to cancer as different personal styles of relationship to risk. She believes that a patient may wish to seek out a physician who has–or at least can accommodate–a style of relationship to risk that is similar to the patient’s own.

Cultures of Cancer Therapy in Different Hospitals

Profound differences in medical cultures also exist among different kinds of hospitals. Some patients instinctively want to find “the best doctor in the field,” whom they define as the chairman of a department at a major teaching hospital that is “on the cutting edge of research” in their particular disease. Nothing is wrong with the instinct to find the “top man” at a research institution, provided you have a clear understanding of what often happens when you seek a physician in that position.

First, your physician will be at a teaching hospital, and therefore you will be subjected to the ministrations of medical students, interns, and residents who are there in order to learn by practicing on you.

Second, your physician will be a leading academic who has made his reputation doing research, and his institution is oriented toward research. This necessarily means that, when he sees you, he sees a possible candidate for a research study. Most good research studies are randomized, controlled, clinical trials in which patients consent to be in the trial and then are randomly assigned to one of several “arms” of the research study. Patients are given one of the several treatments that are being compared with one another, and they are not allowed to choose which treatment they want. Whenever possible, the study is “blinded,” meaning that neither the patient nor the physician knows which treatment the patient is receiving. Finally, the physicians and research staff try to keep each recruited patient in the study if at all possible, which means adhering as closely as possible to the protocol which has been set up for all patients in that wing of the study.

It is, of course, heroic and commendable for patients to decide, in the face of a serious cancer, that they wish to participate in a research study in order to contribute to knowledge that may help save future cancer patients. I have known some patients who chose to enter a clinical trial for just those reasons. But most patients I have known who have entered clinical trials have done so not out of heroism but because a physician they trusted recommended the programs to them, or because only through the trials could they potentially receive (depending on the study design and randomization) treatments they believed held promise.

Oncologists and other cancer specialists know well that different patients may respond to the same chemotherapy or other treatment in profoundly different ways. Some patients sail through a particular course of chemotherapy with minimal side effects; others become very sick. So it is no trivial matter that, in the culture of a teaching hospital, a patient in a controlled clinical trial will be under more pressure to stay with the protocol–even if he is suffering greatly–than he would be if he were treated by an oncologist in private practice. Whether affiliated with a teaching hospital or a private hospital, oncologists in private practice are free to design any treatment program that they wish (within broad limits) for their patients. They can modify the treatment in accordance with the patient’s response far more easily than can a research oncologist committed to a research protocol.

The difference between cancer treatment in teaching hospitals and in private practice is well-known among oncologists. “We’re here to try to cure cancer,” one leading oncologist in a teaching hospital told me. “I often think that in private practice the most popular oncologists are the ones whose patients have the least symptoms simply because they are getting the smallest doses of chemotherapy.” He was suggesting that oncologists in private practice may get more patients by giving lower-dose chemotherapy that may be less curative. Health Maintenance Organizations, or HMOs, which offer prepaid health services that can be delivered only through their hospitals and physicians, present a different set of cultural demands. The goal of an HMO is to provide a high standard of medical care while controlling medical costs as rigorously as possible. The amount of time the patient spends with a physician represents one major cost and medical procedures represent a second. So while the oncologist in private practice is often paid in proportion to the number of patient visits and procedures he undertakes, the HMO physician is encouraged to ration time and procedures as much as he reasonably can.

For the cancer patient, HMOs often mean a very restricted choice of physicians, longer waits to see doctors, less personal relationships with the doctors, and very brief doctor visits. But HMOs also mean far less pressure for potentially unnecessary medical procedures–and a heightened risk that some procedures that might be helpful will be missed.

Cultures of Care, Cultures of Competence

Cancer treatment specialists also differ widely from one another in their capacity to provide competent treatment and in their capacity to care deeply about their patients.

Speaking about his specialty, one of my closest oncologist friends said that, in his experience at his teaching hospital, there were a handful of oncologists who were extremely competent and very committed in the care they provided for their patients. Then, he said, there was a larger middle group in which care and commitment were more hit-or-miss, depending on the patient and the day. Finally, he said, there was a third group whose patients he was very concerned about because their doctors had neither sufficient competence nor commitment. Of course, such differences in competence and commitment are present in every profession: a minority at the top who are exceptionally capable; a large middle group possessing varying capacities; and a group at the bottom end whose clients are at serious risk.

But my oncologist friend added another note: some of those whom he would assign to the third group (medically incompetent and uncommitted) were heads of departments or famous in their specialty fields. Fame and position, in his view, were neither necessary nor sufficient evidence of competence in oncology practice.

Choice in Conventional Cancer Treatment

As I explained earlier, I have used the term culture broadly to describe differences of many kinds among conventional cancer treatment specialists. Let me summarize what these differences can mean to you as you begin to map choices in your own conventional cancer treatment:

Be aware that American cancer treatments are generally at the “aggressive” end of mainstream cancer care when looked at from an international perspective. Know that less aggressive treatment choices are more widely sanctioned in other advanced industrial countries.

Be aware of the debate within conventional cancer medicine on how greatly advances in chemotherapy and radiation therapy have contributed to cancer survival, with strong differences of opinion between those favoring more aggressive treatments and those taking more conservative positions.

Be aware of the cultural differences in American cancer medicine–starting with the differences between surgeons, oncologists, and radiation therapists; the differences between aggressive and conservative orientations in each of these specialties; the differences among hospital cultures of cancer treatment; and the differences in competence and commitment among individual physicians.

So if you decide that you would like a second or third opinion, you are only doing what virtually every physician would do if he or a member of his family had cancer. With these maps of the cultures of cancer therapy, you may be better able to sample the kinds of second and third opinions that can be of most use.