The Cancer Patient for Whom Surgery Is "Too Late"

This is a distressing situation for all concerned. The family has been told by one physician, associated with another institution, that the case is "too advanced" or "hopeless," that the "cancer has spread," and that it is simply a question of time. A surgical consultant is called in for a reevaluation of the patient's condition. A possible advantage of this consultation may be that in this fresh review of the entire case an alternate diagnostic or therapeutic method may be discerned. No reputable physician declines another qualified opinion. If the situation is confirmed to be not amenable to surgery, then other alternatives may be suggested. An adequate single-shot consultation of this kind requires that all the X rays and various reports from other hospitals and physicians be available for review.

No biopsy has been done. Is it possible to be sure without actually having examined a piece of the tumor? A biopsy eliminates this problem because it gives an exact tissue diagnosis. Where this has not been done,uncertainty can exist. However, very often the X rays and physical examination are diagnostic of themselves. Is it possible that the X rays indicate something else? There is always a possibility. Rare and unusual diseases can resemble a cancer. Generally, however, when all the X rays of the chest and bones and intestinal tract are reviewed, the diagnosis can be very accurate. But there are exceptions and these are what we are considering.

Can the biopsy interpretation be wrong? 

The diagnosis in the form of the interpretation of the tissue is made by the pathologist. In difficult problems pathologists may differ just as other people differ. It is a universal courtesy that one hospital pathologist will send the slide to another for an independent diagnosis. This slide review is a common way of getting another opinion on the removed tissue.

How can you be certain that the tumor has so spread as to be too advanced for removal? 

An X ray of the chest definitely shows that the tumor is now scattered through both lungs. Abdominal examination reveals an enlarged liver, which contains cancer, as well as abdominal fluid that results from cancer in the abdominal lining. Above the left collarbone there are enlarged glands containing cancer.

Is there something to be gained by surgical removal of the tumor even though it has spread? Will it prolong life or make for greater comfort? 

In general the answer is no. However, we sometimes operate on advanced cancers to improve the flow of bile or intestinal contents. Thus, if we can improve the yellow (jaundiced) patient by rerouting the bile, then this is worthwhile. The same detour procedure may be done for intestinal blockage. Neither of these is necessarily associated with a better existence in every patient.

This man was completely well three months ago. He's been under a doctor's care all the time. Can it all occur so quickly?

It happens. There is a great variation in the rapidity of tumor growths and in the individual's own resistance. Some people appear to have remarkably little capacity to limit or to localize or to control cancer growths.

What can one say? 

These are the facts. Some cancers arise in areas in which it is almost impossible to make an early diagnosis even when it is suspected.

Is there a drug that can kill the cancer? 

Many anticancer drugs are available. Some are effective some of the time when either used alone or in several combinations or in conjunction with radiation. None of the drugs is effective all the time. The problem is that the same medication that kills the cancer cell may also injure the good cells. These same drugs can be general body poisons.

Can't the effective drug be given just to destroy the cancer? 

There is a technique for doing this in which only one area is subjected to the medication. This is called perfusion. The drug is given into the artery and taken out of the vein of only the involved area. A few select cancers of the skin and jaw area appear to be benefited by this method.

Can the pain be relieved? 

Narcotic drugs can be used in increasing doses. We don't concern ourselves with addiction for this problem in which the lifespan is presumed to be short. Of course, these narcotics depress the individual and can change the entire personality and behavior pattern.

Is there any other way to control pain? 

Yes, one technique, which is now well developed, allows for a destruction of the pain-carrying nerves in the spinal cord. It has some side effects in that the temperature sense is also destroyed. This operation is called a cordotomy, which can now be done by needle puncture through the skin.

What is the life expectancy of a patient with a cancer that has already spread to the lungs?

It is impossible to answer that for any single patient, and it depends on where the tumor started. Patients who have had cancers of the stomach have a lower survival rate than patients with cancers of the colon. Some patients go much longer than the statistics indicate, so one may question the original diagnosis.

Do you suggest further surgery? 

The cancer has spread into areas from which it cannot be completely removed. The biopsy diagnosis confirms this fact. Surgery will not cure cancer that has advanced to this stage.

Is there any advantage to getting still another surgical opinion? 

You have to do what you want. You should be cautioned against injudicious shopping around lest you get unfounded hope from prejudiced individuals.

How about the miraculous cures reported from going to some of the holy places? 

There are times when this problem passes out of the strictly surgical realm into that of philosophy and religion. Most surgeons would be of the opinion that they are not competent to advise you in this matter.

Why did they let him come out of the operation if they knew he had no hope and would be miserable and in pain? 

Wouldn't it have been more merciful and better medicine to have let him pass into an anesthetic sleep? The surgeon does not see that as his role.

Can't you take out the diseased parts and transplant? 

The family would be willing to donate organs. Surgery for cancer has not reached the stage where this kind of transplantation can be considered to be beyond the investigative stage.