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DR. STEMMLER’S MONTHLY TEACHING ROUNDS

OCTOBER, 2002

CANCER Ė A HOLISTIC, PATIENT-CENTERED APPROACH

(COPYRIGHT STEMMLER, 2002)

Understanding the Patient with Cancer

Cancer, curable or not, is a life-changing disease. And as such, it must be handled by the physician with utmost respect, endless patience, and profound compassion for the patient.

The mere diagnosis of cancer cuts into oneís life with a blade so sharp as to divide it into a life before, and a life after the diagnosis. Gone are the free-spirit days, the comfort of selective procrastination, the spur-of-the-moment adventure. Suddenly, the whole perception of time changes, and so do attachments of all kinds. Former priorities lose value and much of what was in storage for later, rises to a high-priority level.

Patients diagnosed with cancer become acutely aware of their mortality, often feeling alienated from the rest of society, for whom death can be rationalized and displaced as a matter of old age. The difference between "knowing" and "not knowing" is a giant existential gap. Physicians treating patients with cancer must understand that their patients live within a different world reality, treading a lonely, narrow path between the living and the dead. When interacting with such patients, listening becomes far more important than talking, so as to graciously enter the patientís world of thought, without imposing the physicianís values, and thereby validating the patientís unique perspective and special needs.

The Choice of Treatment

The initial choice of treatment will ultimately determine the course of the illness, quality of life, and length of survival for each patient. Physicians are often as scared of the disease as are their patients, and consequently they tend to endorse the most aggressive treatments, based on an almost magical belief that "more is better."

Especially when cancer is the disease, where and whom the patient consults at the time of the diagnosis can be vital or fatal. A rushed decision; a disregard for the patientís wishes or their physiological, emotional, and spiritual needs; and automatic enrollment into a treatment protocol, are all factors that have a negative effect on the patientís illness.

In addition, cancer is also a confusing disease; except for a few rapidly fatal cancers, such as pancreatic cancer and mesothelioma, most cancers do not have a clearly predictable course. While some patients succumb to their illnesses at an unexpected speed, others survive far beyond even the best estimates.

So what would be the best role for physicians in advising a patient who is newly diagnosed with cancer? More than ever, with this illness, the physician must serve as an advocate, a teacher, and a counselor. Perhaps the physicians are real knowledgeable in one particular approach; they may share that with the patient, but avoid coercing the patient towards their personal preference. If the patient is not comfortable with this approach, it might be time to refer them to somebody with a different perspective. Unfortunately, too often patients are sent for second opinions to physicians thinking alike, so that the second opinion is just added pressure on the patient to comply with the first opinion.

Patients must be given options. The option of treatment versus no treatment, of fully engaged treatment versus selective treatment, of treatment with one physician versus another, of treatment in town versus out of town. It is wise for the physician to counsel and suggest, yet as ethical professionals, we are not to impose our beliefs on patients, precisely because the patientís autonomy is perhaps the strongest determinant for long-term survival.

Improving the Patientís Quality of Life

Cancer is a feared and serious illness, but it is the current treatment standards which make it a truly dreadful disease.

Oncologists surveyed at various cancer centers about their willingness to accept chemotherapy if they had cancer themselves, responded by a vast majority that they would not. In fact, the more familiar they were with certain treatments, the less likely they were to consider them for their personal use. Such attitudes suggest that chemotherapy and radiation may just be some ugly, nasty procedures we are reluctantly willing to perform only on patients "so that they might live." But of course, when one asks the general population if they favor quality over quantity of life, the overwhelming response is to preserve quality; living wills attest to that.

As physicians, we must have a soul-to-soul conference with our patients and establish how they would like to live. Too many times, family members of patients who have died from cancer "after a courageous battle" (fighting the disease as well as the treatment) have told me, "If I had known then what I know now, I would have never put my mother through such agony."

Fortunately, there are new approaches to cancer on the horizon, but still too many patients do not have access to those kinder, more common-sense treatments and supportive measures. Some of them are cutting-edge technology, while others have been around for centuries. Very promising treatments in the immunotherapy field, are, unfortunately, still mostly experimental in this country. Duke University already offers an immunotherapy approach for certain urological tumors Ė kidney and prostate Ė although presently restricted to research protocols. Dendritic-cell based vaccinations are already showing a reduction in recurrence rates and an increase in remission times for these tumors. Similar technology though, is already used clinically in Europe, together with tumor analysis and other exciting immune-modulating techniques.

Patients who refuse chemotherapy should be offered these options, and physicians caring for cancer patients must keep current of where patients can obtain such treatments. With the Internet being accessible to most physicians, such information is easily obtainable. On the other hand, if patients agree to treatment with chemotherapy and/or radiation, Chinese medicine can come to their rescue, as it helps support their body functions, while minimizing and even eliminating many of the adverse effects.

Two examples from my own practice illustrate how individualized care can greatly enhance the patientís quality of life, and may even have a positive effect on the patientís survival rate. Recently, I referred a patient of mine, a 39-year old woman with breast cancer, to a colleague in Germany. Her tumor analysis there showed sensitivity to some chemotherapeutic drugs and resistance to others. One of the drugs proven resistant to her tumor was a component of the chemotherapy protocol suggested to her in the U.S. Had she actually received such a protocol, she would have probably derived no benefit from it, yet endured all of its side effects. Instead, she is traveling in Europe, in-between her individually-tailored treatment courses, and enjoying life to its fullest. I stay in touch with her by phone on a regular basis, and coach her with her self-acupressure treatments.

Another patient of mine, a 50-year old woman with a very aggressive gynecological malignancy, came to see me one week after her first chemotherapy infusion, having lost 10 percent of her body weight in 7 days, at only 100 pounds. Unable to eat, overwhelm with persistent nausea and vomiting, she had also lost her hope to live. Treated with Chinese medicine and working with the family so they could perform basic treatments at home, in-between office visits, she emerged from her almost unbearable state like a phoenix. Within 24 hours of treatment, her nausea vanished and her appetite returned. Within 48 hours, she ate out and went to a movie. Four days later, she worked half a day. The treatment rapidly brought her back to life, rather than restraining her further, as well-intended drugs aimed at treating adverse reactions often do, by adding their own side effects.

Until we develop kinder, less toxic treatments, it is our duty, as physicians, to ensure the best quality of life possible for our patients with cancer. The famous German playwright, Bertolt Brecht (1898-1956) had this to say about the enjoyment of life:

Enjoyment

The first look outside from the window in the morning
The found-again old book
Enthusiastic faces
Snow, the change of seasons
The newspaper
The dog
Dialectics
Showering, swimming
Old music
Comfortable shoes
Understanding
Enjoyment
New music
Writing, planting
Traveling, Singing
Being friendly

Bertolt Brecht

For those interested in further studying the various aspects of holistic, integrated medical care, you may visit our web site at www.integratedmedicine.com or submit your questions by e-mail to: stemmler@integratedmedicine.com.

Christina Stemmler, M.D.


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