11.(29-32) Secrets of Cancer

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29. Cancer Agonistes

   It is a small wood house like Taniguchi's, made of horizontal wood planks, now old, browned and rotting, with a sliding door that fronts the street, with not-so-clean shoji-paper windows and a slanting roof of old, blackened shingles.

   Standing beside Sanya in the vestibule Kimi attends to Sanya's words.

   “Here is Mrs Ohara's house, her given name Etsuko - call her E.   She felt a right breast lump eighteen months ago and my abdominal examination showed a firm tissue bulge in the side of her liver which biopsy revealed to be a metastasis that we shall call ‘met’ . Open biopsy of the breast lump confirmed a breast cancer and further examinations suggested that it was a solitary one. Such a localized met in absence of general spread is not unusual especially with right breast cancer because the connection from vein and lymph vessel drainage between right breast and liver allows cancer cells to grow or be carried in the lymph vessels from the right breast into the liver and implant there and this happens early in some tumor’s life, before the advanced stage where cells get into the artery circulation and seed the whole body.
   According to standard teaching, E's cancer had passed the bounds where surgery could help but I cut it out, leaving a good size margin of normal right breast and put a skin graft from her thigh over the defect. My experience has shown that leaving a cancerous breast in a so-called ‘inoperable’ case worsens life quality in incurable breast cancer because such a breast tumor rots and as it rots it eats away chest wall causing terrible pain for the victim. We did x-ray to the operative site, the nearby lymph node area and the bulge of liver met.  The X-ray does not cure mets but shrinks them for a time and it may prevent local recurrence from the few cancer cells missed by the surgeon's excision.”

   Kimi not understanding all the words gets the idea that E is a hopeless case. Sanya sketches her social data: “E is 36, husband away at war, and 3 children in country with grandparents. Her family – farmers – requested the hospital look after her.”
   Sanya calls again “Yoo-hoo!” from where they stand in vestibule before a beaded entrance curtain. Now, a gray-haired slim woman in working kimono – Hospital Helper – comes from inner room, greets Sanya and Kimi, gives oral report and leads them to the inside, which has the usual low table with cushions for sitting on floor, a kitchenette on left, and stacked household belongings against walls. An air of dank, dark shabbiness hangs over the place, with antiseptic smell of alcohol. The helper makes tea while Sanya sits with Kimi on the floor by the table.
   Sanya says, "E also tried the Maruyama vaccine."

30. Maruyama Vaccine

Kimi knows nothing about the vaccine. Seeing ignorance in her eyes Sanya explains. “Dr. Maruyama interned here and I put him to researching an immune injection against cancer. Using cancer cells, even killed ones, is considered too dangerous because the cancer factor might be transmitted so Maruyama looked for a harmless material that would stimulate the immune system – something that would enhance all immunity and he thinks he found it in the bacterial capsule of modified Bacillus Calmette-Guerin so called BCG tuberculosis bacteria from which he made an extract of as immune injection that he calls the Maruyama vaccine. It is still experimental and the last 2 years have shown it alone is no cure once cancer is discovered as a lump. The problem seems to be that even a strong immune response is limited due to the vaccine-stimulated killer cells' inability to get at all the cancer cells, but it may help against a small number of cells – for example as we find in early stage or after surgical excision or x-ray. And it may help one who is incurable by slowing the course and the mets. It is given as injection every other day and continued for life. It is inexpensive and we are the sole testing hospital. I feel it is delaying perhaps shortening E's suffering. But its most important value may be a little harmless hope to the hopeless.

31. Deathwatch

Sanya returns to the course of the cancer: “E responded well to my surgery and after x-ray treatment for 3 months her breast incision healed with no local recurrence and the hard bulge in liver was no longer detectable. After recovering from the effect of x-ray she felt good and she helped in my cancer research but 8 months ago I detected re-growth of the liver met. Since then it has grown steadily until now it consumes the left half of her liver. At first, E had no symptom and I preferred not to tell her the bad news since the liver has great reserve so that even when part of it does not work the body does not notice. And the left side of the liver is not involved with the major drainage duct for bile so obstructive jaundice with its yellow skin and itching is no problem. But now the back pressure from the stopped-up drainage is causing fluid to drip from the liver into the abdominal cavity filling it with fluid and causing suffering even on slight movement and also causing  malnutrition because E cannot eat with so much pressure on her stomach. So her life's soon ending is predictable.”

   Sanya further explains: “Every one of us is certain to die but ‘When, where and what condition?’ is the question. Predicting the events of dying is still poorly data-ized.” Sanya frowns. “Let me say it better. By‘predicting the events of dying’, I mean being able to tell how much time one has before symptoms will hinder one's life. For example if I find I have incurable breast cancer I want to know as near as possible: How long I will be on my feet? How long my mind will function normally? How long until it will become very painful? and What shall be my exitus, meaning the actual dying? For example shall it be respiratory dying as in lung cancer or many cases of heart disease, with final day gasping for breath in oxygen tent; shall it be painful but quick from chest pain and shock as in coronary heart disease; shall it be starvation with extreme fatigue ending with inability to lift head from pillow and final coma as in a liver met death?”

   “It is very important for an intelligent, successfully psychoanalyzed person like me; but for the average unintelligent or psychologically unstable person it is best not to know. Such a one cannot mentally and emotionally deal with dying, and will become insane with panic, depression, and, practically, give up living at first mention he or she has cancer." Sanya shrugs her shoulders in frustration.
   "But I do not do my research for this doomed civilization I do it for Science Civilization.” She pauses and Kimi is forced to look away – as from photo flash – because Sanya's emotion shows too strongly.

   “Research in this area I call Deathwatch. I wish to remove the horror from dying, and I think it best we desensitize ourselves from the fear by purposely using the word. We collect data on our patients from the moment of first diagnosis and, then, from when it becomes clear they are closing in on the dying process. A research helper – often with incurable cancer herself – is assigned to follow the downward course of a patient passing through stages of dying to exitus.” She indicates the helper who sits at table on left. “Mari here came to me two years ago complaining of fatigue and I diagnosed chronic leukemia and we had good success – Mari and me - because Mari cooperates in the details of her experimental treatment with a type of arsenic chemotherapy developed by the late, great Professor Paul Ehrlich another Nobelist acquaintance of mine from Berlin days. So Mari is now the deathwatch research helper assigned to E at home here and plus caring for E she collects data on E's downward course. ‘Data’ means the vital signs – body temperature, breathing and heartbeat rate per minute and artery blood pressure from arm – twice daily and then other measurement – morning body weight, food intake, urine output. Also she records E's day to day data in her course towards exitus, like the content of daily thought, complaint of pain with specific or location, duration and quality; ability to use muscles, eyes, brain; and any sudden developing events.

   “E’s is only one case and in Science we do not draw strong conclusion from single case. Here we have not the great number of other such cases needed for that. What we are doing is called pilot study, a small pathfinder in a study not done before. It establishes method for future large study and can help such study avoid problems. Let me end with data from our deathwatch on breast cancer, which will show the practicality of the study. She takes memo and marks two curves, horizontal x and vertical y. She explains. “The horizontal x line shows time from discovery – time 0 is start and to exitus by death is time 100%. The vertical line Y measures life quality from 100 at its top part meaning perfect ability to do everything and also quality of life enjoyment and at bottom part at the moment of death the life quality score 0. We construct the curves by first defining Life Quality and what it would include and then defining Remaining Time. Using those, we noted death from breast cancer fell into categories on the graph I have here scribbled.       
 You see the survival and dying timing and life quality contrast between breast cancer with solitary liver met and breast cancer with solitary brain met.”

   "The worst way to die from breast cancer is brain met because quality of life drops sharply and quickly after the try for cure and there is prolonged helpless suffering and shortened good quality life. This data has allowed patients with early brain met to use the knowledge to help them decide to seek voluntary exitus which I carry out with consent of close family and in secrecy."
   Sanya points the curve of liver met which has best quality survival. "A breast cancer patient with liver met survives nicely with little disability during 85% of the course of the cancer and experiences only little pain even to the end. Thus the patient with liver met has relatively optimistic data and no rational reason for ending life early so she may wish to use the timing to plan accordingly.

   “There are other patterns of met from breast cancer and each has its mode of dying. Also mixed cases and I do not wish to leave impression that merely looking at graphs could tell every breast cancer patient what she should do. Individual variation is involved but even so the first result of our pilot study has helped some patients make important life decision. In E's case the data allowed her to plan out this last year. But now it is ending.”
   Sanya folds the paper and hands it to Kimi as memento also with wishful thought that it will stimulate this girl down a right pathway. She ends saying “This is introduction to research and is not meant to give exact final answer."

32. To Tell or Not to Tell?

“I detected recurrence of cancer in E's liver one day feeling her abdomen. She had no hint. She believed the x-ray radiation treatments, the surgery and the vaccine had cured her cancer.
   “It brings up ‘To tell or not to tell?’ My profession prefers to keep patient in dark about cancer – not to inform of its diagnosis initially or its recurrence after successful treatment. Suppose a narrowed coronary artery supplies blood to a vital part of one's heart muscle and it has not caused obvious symptom. But one day I take an electrocardiogram and see from it that the artery is narrowing and obstructing, and I know that when it blocks up it will kill at once? Today in 1945 nothing can be done to restructure or replace the artery segment and no medicine alters course of the deadly disease.
   What if you are that one patient and you are happy in life and with one spoken sentence telling your diagnosis I can destroy the happiness and turn you into depressed person afraid to take one jolly step further and I exchange no benefit to you for ruining your happy life; rather I sacrifice it purely on the altar of truth?”

   Kimi recalls the doctor she met on the train north.

   “In that case it may be wise not to tell. But not always; for if we live in a society that values telling truth at any cost under all circumstances and punishes those who withhold it or if the person with the mortal diagnosis is a president who is deciding to run for reelection, what then?
   So you hear here, dear, that a physician must be a super Solon, an Ancient wise fellow. In E's case, there was no treatment that could reverse or remove the cancer recurrence. To inform her of it at its discovery was to pronounce a death sentence and make mental misery so I chose not to and I did not have to lie since she did not ask. Because of my decision E had one summer of happiness.  
   To read on, click 11.(33-37) Secrets of Cancer 2