A lot of folk wonder if social media and its rapid growth and development to become in contemporary times almost part and parcel of our daily life is a good or a bad thing. While this argument will doubtless continue for many years further, one positive chance associated with social media such as Twitter, is to allow the previously ‘unseen masses’ of society, whatever their age, background, intellect, or social standing, to have their say about anything they feel, or write a narrative tweet or series of tweets about their own life, and even if they only have ten followers, they all have an audience. One thing I have noticed more often recently is folks describing in detail on Twitter when they are not well, and what the cause of their illness is, from testing positive for Covid to coming ‘clean’ after an alcohol addiction. Its also noticeable that these health-related posts get a lot of likes and encouraging tweets when they are posted. Particularly poignant are the announcements on Twitter of folks who have had a cancer diagnosis and who announce this publicly to their followers, and then continue to tweet further over the next few months or years chronicling their small triumphs and tragedies, or describing how they are ‘fighting’ their ‘body invader’ and will not be ‘defeated by it’. Sadly, a lot of these Twitter ‘life stories’ end up with a note posted to their Twitter account from a partner or family member, saying that the person who usually wrote the tweets had died, as the final post of these tragic tales. Cancer has always been a subject of interest and concern to me, both as a person from a family with a history of cancer who has young children and a desire for more life to be lived, and as a medically trained doctor and scientist. As a teenage boy, one of my most vivid memories was of my father telling me the story of how his own father had died. He described how my grandfather had been driving into town – Durban in South Africa – with my father, who was in his early twenties, when he suddenly started vomiting up blood in the car. As my father told it, they only had handkerchiefs to clear up the vomited blood, and after doing so as best possible, he swopped positions with his father in the car and drove him to the nearest hospital. Sadly, medical tests showed my grandfather had terminal stomach cancer, and he died not long after this vomiting event in the car. What I remembered was the emotion and feeling my father had when telling the story, and it was obviously clear that both the shock of the experience of having the driver of a car he was in suddenly vomiting blood, and the knowledge that this person was his father who was seriously sick, had affected him for many years afterwards. Around twelve years ago my father, who lived six months of the year in the UK and six months in South Africa, boarded a plane to start a routine block of time living in South Africa. He had been feeling unwell for a few weeks before leaving, complaining of a nagging chest cold and a feeling of being exhausted all day, and a visit to his local doctor had resulted in a diagnosis of a chest infection for which he was sent home with antibiotics. On the plane he started coughing up bloody sputum, and this frightening development continued for the rest of the flight and after he had landed in Durban. He was immediately taken by my mother and siblings to hospital, and his chest scans showed the dreaded signs of late-stage metastatic cancer – big ‘cannonball’ lesions in both his lungs, and I think in his liver too – of a tumour that was finally diagnosed as being a melanoma (skin cancer), of which the primary site was never found. He went on a course of chemotherapy and what was then a new form of cancer treatment called immunotherapy, and these treatments made him feel frightful – nauseous, night sweats, itchy skin and other terrible side effects – but the treatments had no discernible effect on his cancer trajectory, and he died a few months later after a terrible time leading up to his death. I therefore clearly have cancer ‘in the family’, and there is a high chance I will one day get a similar dreaded cancer diagnosis that will cause me to ‘shuffle off this mortal coil’ in a painful and terrible way, unless a heart attack gets me first. In this article therefore we will examine cancer as an entity, and whether it can ever be ‘defeated’, and how it affects those that it does like a crab ‘locking its claws into the tissue of its victim’ with a deadly and ever tightening grip.
In the actions of the physical components of the body, which are necessary for maintaining life processes and functions, there are two things that are miraculous to me. The first is that from a genetic code perspective, one’s body grows by multiplying cells controlled by a genetic ‘map’, which over the years of childhood and adolescence increase in number and type until eventually a fully functional adult human is created, with a body that is astonishingly complex and with many different organs and tissues, and at an even deeper level millions of cells operate synchronously both spatially and temporally in order to maintain physiological function and keep us ‘alive and ticking’ in a manner which occurs in a similar way in all of us humans. The second miraculous event is that the genetic code and cellular structures know when to stop growing, and cells know when to stop dividing, when the genetic ‘map’ is complete in the physical realm and no further growth is needed. This is controlled by a still-not-well-known complex system of negative feedback mechanisms, either from suppressor genes which ‘switch off’ gene function, or by protein structures made by the genes themselves which similarly ‘switch off’ genes or reduce the expression of genes (i.e., stop it producing more proteins) when activated as part of an ‘epigenetic’ feedback loop (basically, non-genetic structures acting on genes to attenuate the production of further non-genetic structures by the genes). When a gene gets damaged, there are also protein structures – telomerases – which either ‘fix’ the damaged gene, or cause ‘senescence’ – cellular death of the structure made by the faulty gene. All these control mechanisms keep us well and in a steady ‘homeostatic’ state of optimal existence, which enables us to live our lives both healthy and cancer-free.
Unfortunately, when a cancer ‘begins’, something in one of these ‘suppressive’ mechanisms goes wrong, and the gene that is ‘reactivated’ by the lack of suppressive activity starts creating protein material at increasing speed, and eventually a visible growth of particular tissue activated by the faulty gene become evident, and causes pressure effects on surrounding tissues which often results in the first symptoms one ‘feels’ as a result of a cancerous growth, or by a still not well-known process, starts damaging and destroying cells around it by releasing enzymes or other activating mechanisms that cause cellular damage around and in the tumour tissue (a growing tumour that is well circumscribed is usually ‘benign’ and can only kill one by pressure effects, while if a tumour starts scavenging and damaging surrounding tissue it is generally called ‘malignant’, and is clearly a worse situation and worse diagnosis to have. Cancers are defined by the type of tissues which are multiplying abnormally – for example when epithelial cells (those cells that line the organs of the body) it is called a carcinoma, when lymph gland cells it is called a lymphoma, and when bone or surrounding bone connective tissues cells, it is called an osteosarcoma. If it is found in a specific organ, that organs name is added to the name – for example a lung carcinoma is a cancer of the epithelial cells of the lung, and a hepatocarcinoma is a cancer of the epithelial cells of the liver. For reasons that are still obscure to us, different cancers develop at different rates and kill folk more quickly or more slowly – for example pancreatic and liver cancer are particularly speedy and kill quickly, whereas prostate cancer takes years, even decades to develop. and several folks with prostate cancer live to an age where other age-related illnesses kill them. Similarly, some cancers respond better to treatment than others – for example a testicular cancer has a relatively high success rate from treatment, whereas lung cancer and melanomas once they have metastasized seem to have very low response rates to treatment. Having said that, it appears also dependent on the individual tumour themselves, with some folk lasting several weeks, while others last several months or years, with the same diagnosis and cancer type and stage.
The first million-dollar question associated with cancer (the second being how to treat it) is what causes the gene to mutate or the suppressor functions to ‘go wrong’ and begin the terrible process of abnormal cell division, malignant growth into surrounding tissue and eventually the death of both the surrounding organs and the human being eventually themselves. Many different causes have been suggested. Radiation of cells has been suggested to be a major factor in causality, given the number of folks who developed cancer after the atom bomb explosions in Japan during World War 2, or folks at Chernobyl and Fukushima and other places which have had nuclear disasters and subsequent radiation-induced damage to folks living in surrounding areas. Toxic agents like tobacco and smoke inhalation are also thought to be carcinogens (cancer causing substances or agents). Asbestos in building structures has been linked to cancer, as has exposure to Teflon coated products. Infective agents have also been linked to cancer, with several oncoviruses (viruses causing cancer) including human papilloma virus (predominantly cervical cancer), Epstein-Barr virus, Hepatitis B or C, and many others are linked to cancer development, as have infection with parasites such as schistosomiasis – which is more commonly associated with bilharzia – suggested to cause carcinoma of the bladder. Many types of food have been thought to be linked to cancer – for example eating betel nuts being linked to mouth carcinoma – and examples of whole population studies of countries whose people ingest country-specific diets such as the Japanese who have a high salt and high fish and rice diet show them to have a higher incidence of stomach cancer, while folks in the USA, who have more red-meat in their diet, have more bowel cancer than the Japanese, though in contemporary times, as Japan changes to a more Western diet, these differences are becoming less. Interestingly, folks who immigrate to a new country tend to pick up the same levels of cancer types prevalent in their new country rather than in their old country within a generation of living there. I have to say I am a great believer in Occam’s rule in science, which suggests that the simplest answer to any question is usually the best, and when there are so many suggested causes of cancer initiation, I do believe this means we have no real idea of exactly what triggers cancer development definitively (at best these data show that many factors could be involved), and research done by future generations will give us better answers then we have now, and perhaps also provide us more peace of mind by reducing things we currently worry about as being potentially causative of cancer such as those described above.
Whatever its cause, the most important beneficial outcome of a cancer diagnosis is identifying the tumour as early as possible. A major problem though for early identification is that most symptoms of cancer are generic (could be caused by several different illnesses and pathologies), and by the time one has specific symptoms, the cancer has become late stage and thus more difficult to treat successfully. Paradoxically also, because most folk are so scared of having a cancer diagnosis, they put off getting a check up on worrying symptoms or signs, and go for a medical check-up when it is too late, or when a major medical emergency results from the primary tumour or from one of its metastatic sites, such as a seizure from a brain tumour, or like my father, coughing up blood on an aeroplane. The early signs are often nebulous – again, in my father a cough that wouldn’t go away, in bowel cancer weight loss and bowel habit changes which are ignored as being caused by old age or stress, or in prostate cancer signs of changes in urinary habits, again, that are often put into the ‘I’m getting old’ category of causality and ignored until too late. Often cancers are picked up at routine checks or when one needs a medical certificate of wellness for travelling or moving to another country, or other such unexpected occasions. In young folk and children, it is even harder to diagnose early, as they have so many aches and pains which are generally regarded as ‘growing pains’, and children are often sick from respiratory and gastro-intestinal infections, which also confuse diagnosis. When a diagnosis of cancer is suspected, a medical practitioner will look just not at the local symptoms, but will do whole body scans or a wide variety of blood tests, to see whether it has spread around the body, and the cancer is ‘staged’, with stage one being very localized and more easy to treat, and stage four being very advanced and spread to several body areas, and obviously stage four has a far worse prognosis for successful treatment than stage one – but again, as so few folk go to the doctor with mild symptoms, it is sadly often the case that cancer is picked up ‘too late’ / at a stage three of four level. We will discuss cancer treatment and its problems shortly, but sadly, while there has been some improvement in cancer survival rates over the last fifty years, most of this improvement has been due to earlier diagnosis and more energetic screening programs, rather than due to successes of the treatments currently available themselves.
The mainstay of treatment of nearly all tumours (except of course blood-related tumours) is surgery. Particularly if one has a stage one tumour which is well circumscribed and where there is no evidence of tumour metastasis, one has a good chance of surgical removal of the entire tumour occurring (usually incorporating some healthy tissue around the tumour as a precaution), resulting in a successful ‘cure’, at least in the short term. Sadly though, cancer is the Latin word for ‘crab’, and cancer is named such because like a crab it is not often round and well circumscribed but rather has ‘claws’ of malignant tissue reaching up unseen to the naked eye into surrounding tissue, or spreading to lymph nodes, or to areas further away, and surgery may miss some of the cancer, with the predicable disaster of the tumour growing back at some time point after the initial operation. Cancers also for some reason still not identified cause growth and enlargement of blood vessels into their centre (and have increased level of glucose metabolism which occurs via unusual metabolic breakdown pathways – known as the Warburg effect), which again makes them look like a ‘crab’, and sadly, increases the risk of the cancer cells breaking through into the blood stream and moving off into other areas of the body as metastatic ‘islands’ of tumours, which can grow big themselves in the secondary tissues or organs they lodge in (the second main way metastasis happens is via the lymph nodes). I will never forget when I was a final year medical student at the University of Cape Town, watching a breast tumour removal at Groote Schuur hospital performed by one of the world’s leading breast cancer surgeons, Professor David Dent, from a patient from a rural area of South Africa who had ignored a breast lump, and when David operated to remove it, the cancer was the size of a cricket ball, if not larger. What struck me most though, and which has been the source of several nightmares I have had, was that there were huge blood vessels coming out of the cancer centre (or going in), and David had to spend more hour’s resecting (cutting and tying off these vessels so they did not keep bleeding) these vessels than he did removing the tumour. Even as one of the best surgeons in the world, he could remove the tumour perhaps better than most other surgeons could, but even he could not save the patient, as sadly she also had metastatic lesions all over her body emanating from the breast cancer, and was sent home for palliative rather than curative care a few weeks later.
The other main types of treatment are radiotherapy and chemotherapy, and in more recent times, immunotherapy (stimulating the patient’s own immune system to ‘fight’ the cancer) has become used as a treatment source in some tumours. But, sadly radiotherapy and chemotherapy, which focus on using either radiation to ‘burn out’ the tumour, or which kills the tumour with drugs made up of different drugs which are toxic to the cancer tissue, have the problem of being somewhat ‘blunt’ treatment regimens, and often damage normal tissue, and have many negative side effects themselves, as described above in the first paragraph regarding my father’s cancer treatment and death. They do seem to work better in some cancers compared to others, but as described above, it is not clear how much their use has improved cancer treatment success, beyond that generated by early diagnosis via improved screening methods. I have to be honest and say at this point in time, when I am well, hale and hearty, and having learnt a lot about these treatments, if I had a late stage cancer diagnosis, I am not sure I would sign up to have either radiotherapy and chemotherapy like my father did, due to their major side-effects and because they may give one at best a few months more time alive by reducing the size of the tumour, but those few months extra will be lived with all those negative side effects associated with their use. But, if one of my children or my wife had a cancer diagnosis, and a good doctor I trusted said that chemotherapy or radiotherapy would help them / give them a chance, I probably would not be so bold (or foolish) and would allow the doctors to give these treatments a try, even if the data on their success rates (or rather lack of success rates) is to me appalling. I am sure most folk don’t share my negative perception of chemotherapy and radiotherapy, and one must remember that folk like the world champion cyclist Lance Armstrong was diagnosed with a stage four cancer with metastases in his brain, liver and other organs, and survived after being treated with a combination of surgery, chemotherapy and radiotherapy, and more than fifteen years later after initial diagnosis is still cancer free – though of course he had testicular cancer, which as I have said above, seems to ‘respond’ better to the available treatment regimens than other types.
One of the saddest issues related to folks who develop cancer is that they are often ‘preyed upon’ by ‘quacks’ selling strange supposed ‘cures’ for their cancer and given that they have such a strong desire to live, they often accept these offers of assistance, and pay large sums of money for treatments with no benefit whatsoever, and even use these in place of more conventional radiotherapy or chemotherapy and even occasionally surgical management. A case in point was the actor Steve McQueen, who was diagnosed with a lung mesothelioma with secondary tumour spread to his abdomen and other parts of his body, and who refused conventional treatment and was treated by a ‘quack’ using bizarre interventions like coffee enemas, frequent shampooing of his body, injection of the ‘live’ cells of sheep and cows into his body, and other bizarre treatments, for which he paid thousands of dollars each month. The ‘quack’ boasted he would be cured shortly, but of course these ‘treatments’ had no effect whatsoever on the cancer, and McQueen’s primary and secondary tumours grew rapidly and he died not long after receiving these treatments. There are also a number of ‘quacks’ littered across social media who suggest that they have come up with either a diet, or way of life, or some strange therapy, that if used by healthy folk on a continuous basis, will prevent the subscriber who uses their products from developing cancer. There is sadly no real evidence for any diet or way of life being more protective than others (apart from stopping smoking), and just about every food type has at one time been linked to cancer, or paradoxically, has been punted as being curative of it. Fear of death and paranoia regarding the potential causative effects of daily life on cancer genesis probably drive folks to take up these advertised ‘anti-cancer’ lifestyle choices, which are costly and generally demand a high level of asceticism, but sadly with no real proven benefits in nearly all cases. Sadly, it is very difficult to stop these charlatans and quacks from ‘plying their trade’ on a group of folk who are prone to believe them due to the challenging and terrifying situation they find themselves in when receiving a cancer diagnosis, and one can only be hopeful that in the future, legislation can be passed to prevent the activities of these pathological purveyors of nonsense, but given as described above, the traditional methods of attempting to cure cancer are so tenuous and statistics of cure so bad, that there will always be believers in their nonsense in cancer sufferers who are looking for anything that will give them hope.
Another unfortunate way folks with cancer are ‘preyed upon’, very sadly, is by some cancer specialists, who inflate the price of drugs needed to ‘treat’ cancer, and then encourage folk even if they have cancers with little reactivity to any treatment, such as melanomas and pancreatic cancers to use these inflated cost drugs, knowing that the folks with cancer will do anything, and pay anything, to be given a chance to live longer or ‘beat’ the cancer and re-attain their healthy state. Again, very sadly, parents with children diagnosed with cancer are another group who are ‘easy prey’ for avaricious cancer specialists who offer a cocktail of drugs and therapies at inflated prices. There is nothing much that can be done to attenuate what is for me terrible practice from medical practitioners involved as while it is surely immoral, it is not illegal, other than to be sure to ask the treating physician if the treatment they suggest is the lowest price treatment, or whether another drug of similar efficacy but less cost is available, even though one may worry that one is asking for inferior treatment. With all the above examples, it is obvious that there are challenges facing folks recently diagnosed with cancer beyond just managing the cancer diagnosis itself, such as being sure one accepts help from folks one can be sure have one’s best interests at heart and avoiding the charlatans and sociopaths who cross your path and try and make a profit out of your misery and need to feel hope.
Whatever the cause, or type, or stage, of cancer, being diagnosed with it is one of the most challenging things a person can have to deal with in their life. Even waiting for test results to come back for cancer scans can cause dramatic psychological upset, fear and anxiety, and a diagnosis of cancer for most folk is truly a life changing event, with everything one planned for in the future being ‘thrown out the window’, and suddenly one has to deal with one’s own mortality as a real rather than ‘hypothetical but unimaginable’ future event. There are very high rates of depression and increased incidence of suicide in those diagnosed with cancer. Folk can go through the Kubler Ross stages after being given a cancer diagnosis – denial, anger, bargaining, depression, acceptance – but the progression between these is not always linear, and for most folk life is from a mood perspective, a very much fluctuating ‘event’ post-diagnosis, given that there are periods of hope, periods of great illness when having chemotherapy and radiotherapy, and periods of despair when told treatments are not working as they should, and even when someone is one of the fortunate folk who get told they are ‘all clear’ of the cancer, sadly it returns in so many folk that one cannot feel ever that one is completely ‘cured’, and folk in remission always know that it could return, and have high levels of anxiety for every symptom they feel or sign they see in their body which may indicate their cancer is returning. An interesting psychological occurrence is that most folk tend to externalize the cancer as something that has ‘attacked them from outside’ and that it is not of their body, perhaps because it is difficult to ‘declare war’ on one’s own body when it has let one down so badly as it has when cancer develops from and in one’s own organs. Sadly, most folk, whether a few months later like my father, or several years later for folk with prostate cancer, will be told by their doctor that nothing more can be done to treat their cancer, and that their care going forward will be palliative – relieving pain and complications of the cancer, rather than trying to cure the cancer itself – and that such folks need to prepare themselves for their imminent death as best they can. As it goes, with good palliative care, the end stage and dying process can become relatively positive, given one can give morphine / painkillers as needed, and ensure the last days of the cancer stricken person to be as easy as possible as they say goodbye to their close ones and to their own life itself, though of course, even if folk die bravely and pain-free, nobody wants to die, and it is a shattering process both for the person dying, and perhaps even more so for those who love them and have to watch them die.
Due to a family feud, I did not see my mother for seven years, until two weeks before she too died of cancer in her mid-seventies. I flew across from New Zealand, where I was working then, to Durban, to say my goodbyes to her, and had a final cup of tea with her, and we cried together and I said my goodbye to her and left, never to see her again. She was so thin and delicate, with a belly swollen tight with fluid due to secondaries in her liver and abdomen, and each word she spoke was difficult for her to get out – the cancer destroyed her physically and she was a shell of a human being when she died. I remember also the last time I saw my father twelve years ago – he gave us a huge wave and his customary ‘yay for the good guys’ shout as we drove away from his house in Durban, trying to stay positive even though he was gaunt, pale and sweating from the treatment cycle which he was currently on. I remember being called when he died and thinking both how sad it was, yet relieved that he was peaceful again, after the terrible last few months when he was ‘fighting’ the cancer that killed him. Given my family history, I am sure I too have this terrible diagnosis and end of life ‘program’ ahead of me (though of course while no way of dying is pleasant, to me there are far ‘worse’ ways to die than by cancer, for example Locked-In syndrome, where one’s whole body is paralysed yet one’s mind is fully cognitive to the end, is to me the absolutely ‘worst’ way to die). When I was young, this knowledge used to make me wake up at night sweating with fear, but paradoxically the older I get I seem to have come more to terms with it, and await my outcome and final death diagnosis, whatever and whenever it will be, with a greater degree of stoicism. However, having said this, even with my experience of being a clinician and researcher myself, I still occasionally don’t go to the local GP for a check-up even if I have symptoms that bother me, so at a deeper level I am surely still scared of a cancer diagnosis, even though perhaps not as much as when younger. As described above, even though medically trained, I must be honest and say I would like to think I would refuse chemotherapy and radiotherapy if diagnosed at a late cancer stage and use the last bit of time to enjoy life as much as possible with my family and friends, until the final day of my life arrives and I take the journey into eternal darkness, but let’s see what happens and what decisions I make when a bad cancer prognosis becomes my own fate. As a medical student we had a lecture on cancer given by an old German doctor, who said that if you have a patient with stage four terminal cancer, why stab them with needles each day to check on the status of their blood parameters, and by doing so trying to causing them a lot of pain, only to potentially save them for at best an extra month or two – rather send them home to plant the next crop of corn, and get things ready for life’s next cycle (meaning get one’s affairs in order for one’s children and their future) and I have never forgotten this, and hope when my time comes I will do such. For many of us the crab is floating in the shallow waters just beyond where our toes are dipped in the water, and if or when it bites, it is surely the start of a turbulent journey across the bay to the land on the other side…