Of cure and care: the challenges in oncology practice

Cancer treatment has to be made not only accessible and affordable but also equitable

Over the last six decades, there has been a sea change on the cancer horizon. In 1954, the perception was that it was incurable. The only treatment modalities available were surgery, wherever possible, and primitive high-voltage radiotherapy. Medical oncology had not been born. The growth of scientific knowledge and technology between 1960 and 1980 and the dawn of medical oncology in 1970 saw the advent of the concept of multidisciplinary management in oncology. We moved from cure to quality care, from survival to healing.

Oncology is perhaps one of the most difficult and complex super-specialties in medicine, as complex as the disease itself. W.H.S. Jones said: “Medicine is a difficult art and one inseparable from the highest morality and love of humanity.” The relevance of this statement in the context of ethical conduct and practice in oncologic practice is more than real.

William Osler said the practice of medicine is “an art and a science”. As technology advanced, the balance among technology, science and art shifted towards the former, and thus the practice of medicine became “science and art”. Over a period of time the art component has been gradually disappearing. Osler at a later date said the practice of medicine is “an art, not a trade; a calling not a business”. This is no doubt a reference to ethical practices. The implications of this change in the medical care scenario, especially in oncologic practice, are manifold.

Hippocrates (460-377 BC), who is considered the father of modern medicine, laid down certain basic guidelines for medical practice. These are still considered a model for ethical practice. It was an era when medicine was an “art of healing”, when the physician treated by “listening” to the patient. In the present context of growing technology and multidisciplinary approaches, it is the oncologist’s responsibility to consider how to integrate science and art and ethical practices in oncologic care. Multidisciplinary teams are needed for comprehensive care and practice.

Doctors and patients

The doctor-patient relationship is a special and sacred one — of trust, hope and confidentiality. In oncologic practice, when a patient meets you for the first time, he or she comes in a state of fear, almost verging on panic. The oncologist faces two issues. It is not enough to merely diagnose and treat. One has in addition to meet the emotional and other needs of the patient and the family, stressing the need for comprehensive care.

In meeting a patient’s varying needs, there must be honesty and clarity as to what can be done and what cannot be achieved. This needs communication skills and empathy to create a sense of confidence and trust.

Communication must be clear and without ambiguity, in a language the patient and his or her family members understand: the therapeutic options, risks, benefits, pros and cons of different modalities of treatment and morbidities should be spelt out. The oncologist has to be sensitive to the psycho-social needs of the patient and the family support available.

Ethical practices

The availability of sophisticated technology should not be the sole reason for its use. One has to consider carefully when and where it is to be used, which is better and under what conditions, and what the cost-benefit ratio is. There should be a constant reappraisal centred on improved patient care. One should work towards quality care. Here, unbiased validation comes into play. Marketing practices of equipment manufacturers needs to be monitored. Technology assessment and evidence-based practice becomes mandatory in order to have a clear scientific basis for action and to determine whether they are cost-effective. Evidence-based guidelines often remain in words, not in practice. Ultimately, the patient is the victim.

In oncologic care, the value of multidisciplinary management has been documented beyond doubt. The team-members should have excellent knowledge in their own skills in addition to good basic knowledge of the others in the team.

This will be essential for interaction on equal terms and to speak their language with understanding. The concept of treatment outcomes goes beyond survival and includes quality of life, long-term morbidities, and more.

Cancer is an extremely complex biological phenomenon. The heterogeneity is such that the clinician realises early on in his or her oncologic practice that no two cancers are alike. The greatest challenge in cancer management has been the inability to prognosticate the outcome of the treatment, whether it be in the form of surgery, radiotherapy or chemotherapy.

Molecular biology techniques have opened new avenues and capabilities in the areas of prevention, diagnosis, early detection, staging of disease, monitoring of treatment, prediction of outcome and risk assessment. It can also help detect recurrence, potential for metastases and so on. These have helped in formulating treatment plans based on the biology of the tumour against the background of the host milieu.

Palliative care

Palliative care is a major component of cancer control and comprehensive care, and accepted as a specialty. The yardstick to measure it will be how well or how much one is able to enhance the quality of life of a particular patient. No two patients are alike either in their needs or response.

Palliative care has thus to be multidisciplinary if it has to be successful. It is a dynamic maintenance of quality of life, psycho-spiritual support and relief of symptoms. There should be a delicate and sensitive balance of science and professional care along with social care.

There are times when a patient may need surgical intervention, radiation or chemotherapy. These are areas that abound in unethical practices. In the use of chemotherapy in palliative care, the cost and benefit, morbidities and survival benefit should be fully explained to the family. This becomes necessary in an environment of limited resources. Palliative care physicians must commit to care beyond cure.

Cancer treatment has not only to be made accessible and affordable but equitable. There are very few studies globally that compare the same treatment for the same sites and the same stage of disease among different economic groups.

The difference between the best, the state-of-the-art, the average and the worst is large. It is a reality today in health care and certainly so in oncologic care.

And, a significant number of cancer patients are actually being treated by non-specialists.

(Dr. V. Shanta is Chairman of the Cancer Institute - WIA, Chennai, and a Ramon Magsaysay award winner)