HOW IS CANCER TREATED?
Cancer treatment is complex and typically will involve input from a number of different groups, ranging from a wide assortment of doctors, including general practitioners (family doctors), surgeons, oncologists, pathologists, radiologists, palliative care specialists, as well as a huge number of other trained personnel – nurses, radiographers, physiotherapists, technicians in laboratories and radiotherapy departments, theatre orderlies, the list goes on and on. The details of organization for these different groups vary enormously from country to country and are a function of both the politics and economics of healthcare.
To try and get around this problem, I will present the organization of cancer treatment as a journey from symptoms to diagnosis, treatment, follow-up, and palliative care for those experiencing incurable recurrence. Different health care systems will process these events in a variety of ways, but by and large, the underlying principles are pretty universal.
Cancer Initial diagnosis and investigations
Most patients still present with symptoms such as a persistent cough or problems such as blood appearing in the urine. Significant numbers are also picked up by screening programmes, either organized on a systematic basis (for example, for breast and cervical cancer) or more informally (such as PSA testing for prostate cancer). Some cases are picked up as incidental findings in the course of investigation for some other problem. For example, an abdominal scan may detect an asymptomatic tumour in a kidney. I will return to these groups of patients later.
Most patients will present to their doctor with some sort of symptom they have noticed and which they are worried about. Although symptoms, like people, come in an unlimited number of varieties, they can mostly be grouped into those causing disruption of normal function, such as a brain tumour disrupting normal movement, or abnormal symptoms due to damage by the tumour, such as bleeding, pain, or a cough. The period between initial symptoms and diagnosis of cancer may be very short or may sometimes run for years. Sometimes the delay in diagnosis is down to misinterpretation of symptoms by health professionals, sometimes deliberate self-neglect or self-deception by patients, and sometimes a mixture of the two.
Unsurprisingly, the perception that an opportunity to make an early diagnosis has been missed can cause severe subsequent problems in the relationship between the patient and their doctor, often at a time when they need them most. Family doctors have a tough time in this respect. For example, headache and backache are common symptoms, and in the vast majority of cases have benign causes that may need symptomatic remedies but do not need extensive investigation. Occasionally, of course, these symptoms may indicate an underlying brain or a spinal tumour. Another example is the presence of blood in the bowel motions. All medical students know that this may indicate bowel cancer. All family doctors will know that for patients in the ‘at risk’ age range for bowel cancer, the presence of conditions like haemorrhoids (an irritating condition of the lower anus that can bleed) is virtually universal. How do they then set about distinguishing the banal from the severe (but rare) without grossly over-investigating their patients? The answer often lies in another basic skill taught in medical school – the art of taking an accurate history. Thus, a sudden and unexpected change such as severe bleeding mixed in with motions is much more likely to be due to cancer than a small quantity of bright red blood being seen smeared on the toilet paper occurring over a period of years.