Wednesday, December 15, 2004

I'm humbled

I'm a surgical oncologist, specializing mainly in breast cancer. That means I do surgery on breast cancer patients to try to cure them of their cancer or, failing that, to palliate their symptoms. One big advantage of this specialty is that I generally see patients who actually are "curable." Patients with advanced cancer usually don't get referred to the surgeon (nor should they be, usually), and I usually don't watch to see my patients who recur actually recur, because most recurrences occur after the window of my surgical care (usually around 6-12 months, after which I usually don't see the patient regularly anymore, mainly because the medical oncologist has taken the long-term followup). I can usually leave the operating room satisfied that I have done the patient some major good. Medical oncologists, on the other hand, are the ones who give the chemotherapy and follow the patient for several years. True, medical oncologists who specialize in leukemias and lymphomas can cure a significant number of their patients with chemotherapy. True, some of their patients with solid tumors are simply getting adjuvant chemotherapy after surgery, and the medical oncologist can have the satisfaction of knowing that he or she has improved their chances of living without a recurrence, often by a considerable amount. However, many of the medical oncologist's patients are patients with advanced disease who are not curable. The best that can be hoped for is some prolongation of life and decent palliation of symptoms. Those are the patients medical oncologists treat and follow until they finally succumb to their disease.

Two things made me think of this. First, as a surgeon, you don't generally see your patients recur during training because you are only on one surgical service for a couple of months at a time. Since taking my first faculty job, I've been at the same place for five years now. This means I'm starting to see some patients that I operated on two or three years ago come back to medical oncologists (who are in clinic with me on the same day) with recurrences or metastatic disease. One patient in particular, whom I operated on two years ago, came back last week with widely metastatic disease last week. This happened despite her having had a "curable" (albeit high risk) tumor (3 cm, 1 out of 20 nodes positive for tumor, estrogen receptor positive), proper surgical therapy, and proper adjuvant chemotherapy and hormonal therapy. It made me remember that, even in the case of a tumor the disease-free surival rate is 60% or 70%, that means 30% or 40% are going to recur and die of their disease, even with absolutely optimum therapy. Even for early stage breast cancer (small tumor, no axillary lymph node metastases), which can have a 90-95% long-term disease-free survival rate, that means that 5-10% of these very "curable" patients will recur and die. As a surgeon and a doctor, I'm humbled when I think about this.

The other thing that got me thinking about this is this particular post in Dr. Hildreth's excellent blog. His observations remind me of why I probably couldn't be a medical oncologist (which is actually what I wanted to be before the my third year of medical school) and why I admire those who can do it and do it well. I highly recommend his blog; since I discovered it about a month ago, I never mist a post. He may not post every day, but his posts are worth the wait. If my posts on medical issues can be half as insightful as his, though, I'll have succeeded on medical aspect of the blog better than I could have hoped.

2 example(s) of insolence returned:

At 12/15/2004 2:30 PM, Anonymous Anonymous said...

Just found you through Paul Myers at Pharyngula. If your as good a surgeon as you are an off-the-cuff writer, your patients are very lucky indeed. Keep writing doctor, we'll keep reading.



At 12/16/2004 3:22 AM, Anonymous Anonymous said...

Did you know that cancer can be cured? Yes. It is as simple as certain frequencies of sound, concentrating on the area [speaking mostly of cancerous tumors as opposed to cancers such as leukemia]. Do you know of any research being done in this area, as of late?

A Nurse's daughter


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