| Ch 12 | Page 2 / 13 | |
| Multidiscliplinary approach |
Common history of a localised cancer | |
In clinical practice, there are two different types of cancer discovery:
- Either the cancer is localised
- Or cancer is immediately metastatic.
A localised cancer should be intensely treated with all of the local resources at our disposal:
- Radical surgery (excision of the tumour and satellite nodes),
- Radiotherapy (as a main or complementary treatment),
- Other local techniques.
When the general history of a given localised cancer reveals the rapid development of metastases (for instance for breast cancer), this means that, at the time of local treatment, and although they were not clinically or radiologically visible, remote microscopic metastases did exist.
Adjuvant treatment (chemotherapy, hormonotherapy) is administered
to statistically increase the (disease free) survival of patients, since it
kills most of the disseminated cells.
Once this local treatment has been performed, the patient enters a post-therapeutic
follow-up period.
This is the optimistic message that should be heralded.
The more our knowledge of cancer progresses, and the earlier we screen patients, the greater the chances are of curing them.
There is three forms of relapse:
- Localised relapse,
- Remote metastases,
- Or both.
Some local relapses may be salvaged by surgery or radiotherapy, at the cost of major mutilation or the risk of post-radiation sequelae.
Local relapse rarely genuinely responds to chemotherapy.
Local relapse is most often the result of unsatisfactory initial local treatment either because the limits of excision were not situated within normal tissue, or because the resection was inadequate leaving behind small non visible tumours. The fear of leaving behind tumour residues justifies radical surgery (or systematic complementary radiotherapy when surgery remains limited).
A poorly performed surgical act, or timorous radiotherapy may lead to local relapse with no further therapeutic possibilities leaving the patient to die with various symptoms including pain, fever, foul-smelling, incontinence, and in any case a psychologically degrading situation.
(Occasionally, the initial tumour is developed to such an extent that surgery or radiotherapy cannot give satisfactory results – mainly stage IV – with the same catastrophic local consequences).
Metastatic relapse is generally due to our failure to discover metastatic tumour cells when discovering the local tumour.
Tumour kinetic data enable us to determine what therapies remain possible.
A rapidly occurring metastasis means that it was at the border of visibility (either clinically or radiologically) during the initial examination period. If there is no specific treatment (like chemotherapy or hormonotherapy), then the chances of obtaining long remission with good quality of life are slim. Curing the patient is no longer within our ability (with a few exceptions such as testis cancer).
A late occurring metastasis means that only a few cells were present at the time of initial treatment. If the metastasis is well localised or unique, it may be treated by surgery (or radiotherapy) with a good chance of prolonged quality remission. When many metastases are observed, quality and long-lasting remission may be obtained if we efficient treatment is available (chemotherapy or hormonotherapy for breast, prostate, ovary). However complete recovery (as defined in the chapter on follow-up) is unlikely.
It is very often possible to offer patients a first quality clinical remission.
The aim of modern hormonotherapy, chemotherapy and, in particular new targeted treatments is to offer prolonged quasi infinite remission.
In comparison with mellitus diabetes, in most cases, we do not cure the patient, but by the regular use of insulin, patients are offered a quasi normal life at the cost of a daily or twice daily subcutaneous injection.
A second cancer relapse, particularly if it occurs rapidly, implies a growing resistance to hormonotherapy or chemotherapy and the risk of a brisk evolution towards cancer generalisation and patient death.
Therefore, at this stage, therapeutic resources should be adapted to realistic ambitions.
In the palliative care chapter, we detail the many possibilities of efficiently helping our patients to maintain their human dignity throughout their disease.
When he/she cannot cure the patient, the doctor should not be defeated: he/she can continue to care for and accompany the patient.
Metaphorically speaking, in daily medical practice, we only have a few cartridges available for killing cancer. We therefore need to be very careful not to waste our ammunition.
Cancer surgery is difficult and requires excellent knowledge on tumour biology together with practical aptitude well beyond simple surgical skill. Discovering an ovarian tumour requires digestive surgery proficiency and, above all, time to perform a complete surgical tumour excision. Head and neck cancer surgery often requires the constitution of a team of competent surgeons with experience in digestive derivations, plastic surgery or even neurological surgery.
Radiotherapy should always be administered at its highest tolerance limit: the doses necessary to treat cancer are very close to toxic doses. Quality, effective radiotherapy without any risk is impossible. Therefore, precise dosimetry, complete knowledge and association with other techniques such as brachytherapy, conformational radiotherapy, IMRT or even proton therapy are essential to offer the best chances of recovery to patients.
Even for the most chemosensitive tumours (for example: testicular cancer, lymphoma, placental choriocarcinoma), many medical techniques should be employed such as resuscitation or emergency treatment. Chemotherapy should therefore only be prescribed by experienced physicians who treat enough patients to maintain constant expertise and proficiency. Certain failures are due to insufficient dosage, below the necessary dose intensity. On the contrary, many patients receive pointless, toxic treatments, with no significant benefit, when a genuine, compassionate dialogue between the patient and his/her physician could have led to effective palliative care.
It therefore appears clear that the competence of various medical and paramedical professions should be reunited through a multidisciplinary dialogue to offer patients the best chances to be cured or at least to be cared for with dignity.
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