donderdag 24 januari 2013

Cerro and Imagination

It was a high-level discussion!

High level literally because the conversation was held in a telecabine about 50 m above the ground and 2500 m above sea level.
It took place in Les Menuires, one of the "Trois Vallées", by far the biggest ski area in the world.
Every year, more than 50 radiation oncologists, physicists and biologists come here together for a scientific conference on new evolutions in cancer research.

Every day four and a half hour of skiing were combined with four and a half hours of scientific meeting. This combination made it acceptable to the tax authorities to deduct the cost of the conference..
In no way, it is suggested that this happening could be categorized as a luxury trip where the program was nothing more than an excuse to escape in parties and fun.
On the contrary, the presentations of cancer specialists were very well prepared, they reflected on recent insights in cancer care or research or reports on own experiments.
Every participant did his utmost best to give a well-structured, evidence-based and entertaining presentation not to be embarrassed in this audience of international experts.

Every participant was obliged to attend all the lectures. If not, the participant ran the risk of not being invited next year. In the last couple of years, a growing percentage of the attendees divided their time in the conference room between listening to the speakers and reading e-mails on smart phone or iPad.

However, they tried to hide this by giving the impression they were making notes on the content of the lecture while in reality they were occupied by another world and far away from the hic et nunc of the conference.

Nevertheless it was not in the narrow and dark seminar room in the cellar of the hotel that the big scientific fertilization took place.
The exchange of ideas, the discussions on new insights, the contacts for collaboration in joint research, happened literally in the sky.

It all happened in the telecabine and the chairlift surrounded by the white painted Alps as a metaphoric context for scientific researchers who climb steep rocks, walk by dangerous clips with as a goal the valley at the other side of the mountain, never discovered by anyone else and revealing a new world , once one had reached the top.

In that perspective, the discussions were of the highest level.
"How long will surgeons continue to cut your prostate out of your pelvisasked a German radiation oncologist to her ski group members.
"With our new techniques of IMRT and IGRT, and with our imaging capabilities for perfect delineation of the tumor and with the new evolutions in brachytherapy, it is obvious that in short-term our artillery will overcome the surgeon's scalpel.”

A Polish colleague answered :
 “But if a patient gets the message that a dangerous tumor is found in his prostate, then it will be difficult to convince the patient and also the surgeon that there is another solution than cutting out the tumor : Ubi pus, ibi evacua.
Photons that attack cancer cells are not visible and tangible and furthermore, it's difficult to explain to people why you get cancer from radioactivity when the same rays are used to cure cancer.”

“But maybe our 60-year-old man can overcome these stereotypic ideas”, answered a Dutch radiation oncologist
 “ if he realizes that the surgeon will not only take his cancer but also his continence and potency.”

There was some suppressed laughing under the helmets because the international club of  irradiators knew that this was undoubtedly the ultimate seducing trick to get the man under the linear accelerator or get the permission to fill his prostate with radio-active seeds.
The cabin was fulfilled of powerful "we-feeling" of the professional radiation oncology group in the absence of the competitors as surgeons and medical oncologists, so that they proclaimed their own victory.
A little bit like a football team that after the strategic instructions of the trainer, has already played the match in their imagination whereas the result cannot be discussed anymore.

"So what is the situation regarding prostates in Australia", the Dutch woman asked to her colleague from down under.
“I think urologists and radiation oncologists should be more aware of the side effects of the treatment”, the Australian answered.
“Do you know that in the big trials from RTOG and EORTC most of the side effects of androgen suppression weren't even registered.”
The Dutch replied : “Nevertheless radiotherapy in combination with this hormonal treatment implies an increase of survival of slightly more than three percent and you must admit : people go for survival regardless of any side effect.”
“I disagree with that", replied the Australian , "Are you sure that all the side effects as sexual dysfunction, fatigue, osteoporosis, and elevated risk for heart attack are discussed with the patient or are even known by our colleagues?
Can 3% of supplementary survival be considered against 10% of the people who have permanent sexual dysfunction, fatigue or other complications?
There was a good study in Nijmegen where patients were asked to choose for better survival or more side-effects.
Most choose less side effects.”.

“Shouldn't we take quality-of-life as a main endpoint in the discussion about these kinds of treatments?” the German lady asked.
But the Polish woman replied : “All this quality stuff is nothing more than people who are designing questionnaires and trying to quantify what cannot be quantified.
Surviving cancer, that's quality-of-life!".

Surviving this snowstorm", the ski monitor warned, "that's quality of ski”The cancer hunters put on their gloves and their helmet and followed the ski leader and each other to look for the right way to go down.

In the evening session a special guest was invited by the Italian president of the society.
Ivan Illich was born in 1926 in Vienna and he studied chemistry in Florence and history and philosophy and theology in Rome.

He obtained a PhD in Salzburg on Arnold Toynbee.
As a priest he worked for the poor in the upper West side of New York and in ‘61 he founded Cidoc in Guernavaca Mexico, an education center on liberation theology.
Due to a conflict with Rome, he resigned as a priest and from ‘79, he was professor at the universities of Pennsylvania, Berkeley, Marburg, Kassel and Bremen.
He died in December 2002 of cancer at the age of 76.

Illich was invited because the Italian, during his presidency, wanted to make a point of ethical aspects of leadership in an oncology department.
In a memorandum of understanding the key issues of Illich's speech were written down, the length of his talk in minutes, the number of questions he could answer and the fact that he would not ask for a speakers fee because it's a gold standard that all lectures at ESTRO congresses are for free so that the organization can make a reasonable profit out of it.

There were no chairs left in the small seminar room and some people seemed still a bit dizzy of skiing or red-faced from the sun or the after ski bath and some radiation oncologists and physicists seemed a bit disturbed by this "PSYKO lecture" and were busy reviewing a recent article for the Green Journal.
Others were still continuing their ski conversation : some about their kids being left with the grandparents and others about the initiation of a joint trial on a new treatment for rectal cancer.

The president introduced Ivan Illich remembering that patients are the ultimate goal of all their efforts and their well-being and spirit had  to be taken into account above anything else.

Illich referred to his book "Medical Nemesis", written in 1975 where he distinguished three kinds of iatrogenesis, the sick making adverse effects of healthcare.

“The first one Medical iatrogenesis”, he started, “ implies the direct medical side effects of treatments preventable or non preventable; this counts for about 10% of all diseases treated in healthcare in the United States in that time.
The second one Social iatrogenesis has to do with the addictive behavior of the population to medical care as a consequence of manipulation by the medical care system which sets its own economic goals.
In 1975, global healthcare spending was about 10% of the GDP in United States.
I predicted that this would double in the next decades and I invite you to consider the situation where healthcare expenditure will be up to more than 50% of GDP; that means that more than half of the economic activity has to do with healthcare or that one half of the population would be caring for the other half of the population.
Could you imagine a sicker society than that one?

The third one Structural iatrogenesis has to do with an almost metaphysic belief of the population in the progress of healthcare.
Pain is a point on a scale and  can perfectly be controlled and managed.
Disease is a biochemical accident that is resolved by medicine now or at least within the near future and death is not an event that happens but a decision made or by the medical profession (decision or treatment) or by the patient (euthanasia).
If medicine creates the illusion that pain, disease and death are just biochemical processes, then these phenomena are the matter of only professionals and the patient is losing his ability to cope because he is out of the game.
I would call this alienation a major determinant of unhealthiness.
Health is not the absence of disease but the ability to cope with pain, illness and death in what I would call a convivial way.
If medical care contributes to more autonomy and the ability to cope with existential problems, it contributes to the health of the patient.”

When he stopped talking, there was a silence.
The Italian president realized that the memorandum of understanding had not fulfilled his aim and he felt part of a kind of hostility that was hidden in the audience.
"Do you mean that healthcare is useless, mister Illich", a Belgian radiation oncologist  started,"that we have to move back to nature or religion where sickness is natural and has to be accepted as a punishment of God?"
It was not the first time that Illich had to tackle this question and he replied :
Modern healthcare has taken away a lot of suffering and disease.
Personally, I don’t believe that ischemic heart disease or cancer or even infectious diseases will ever be banned out of life but it's an honorable profession to relief pain and disability as long as it keeps the understanding, the initiative and the choices with the patient who keeps responsible to give these phenomenon a meaning in his life.”

"Mister Illich”, replied the Belgian, “if your criticism is so sharp on medical healthcare, why don't you take your responsibility  yourself in terms of changing the system."
"I'm a thinker, I'm not an implementer and I can only hope people who are in powerful and influential positions will read my book and that they will be inspired by what I wrote."

“Is your book a plea for more prevention?” asked a Polish radiation oncologist.
“Prevention is ok if people take responsibility over their health but I knew a man who was so preoccupied by his fitness and his health that he hadn’t any time to do something else.
He died from nothing.”

 "Do you think, mister Illich that there is a correlation between a kind of mental force or eagerness to survive and the outcome of let's say cancer treatment?" a Danish radiation oncologist asked.
His "I don't know" was disappointing.
A few radiation oncologists in the audience were in favor of that idea.
A Dutch radiation oncologist referred to the promising impact of immunological treatment in cancer.

A Belgian psychiatrist, who coincidentally stayed as a guest at the hotel, attended the lecture, and he referred to psycho-immunology.
“I’m fascinated about the contradiction that radiotherapy is healing cancer but can also cause cancer in middle or long term, that chronic inflammation for example in colitis ulcerosa, is a precursor of cancer but that an inflammatory response is assumed by the Dutch radiation oncologist to be a weapon against cancer and that hypoxia leads to necrosis in the tumor but paradoxically also protects the tumor against radiation treatment.”

The radiobiologists started a discussion about the ongoing research in overcoming this resistance by targeted agents or focused radiotherapy and dose painting.

"This is too much of a speculation", argued a Dutch physicist
“What you see is what you get, that's what I believe and I think we shouldn't waste our time with philosophical debates on the origin and meaning of cancer but my work is trying to set up new imaging techniques so that cancer can be destroyed and vital tissue can be preserved.”

"Imaging or imagination" the Belgian chair of the session asked the audience..
"Imagine" Illich repeated, "that all disease would be conquered and death was nothing more than an accident or human error."

He received a polite applause and left the hotel for a walk in the mountains.
He thought about Weinberg and Hanahan, while they were walking on the Volcanos of Hawaii and aimed that for the current generation of oncologist the world would change dramatically.

His thinking went to Lance Armstrong who conquered cancer and won the Tour de France up to seven times but lost all victories because the goal in the mission were more important than being a good sportsman who can balance his ambition with his strenghts and shortcomings.

He looked at the sky far above the mountains and he imagined that he saw the wings of Icarus who tried to reach heaven but his wings of wax were melting when he came too close to the sun

"Hubris", Illich said to himself, "and Nemesis the goddess of revenge."

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