Domhnall MacAuley on a dead certainty

Domhnall Macauley

So, who gets cancer? Have you a mental image? With heart disease, our classic picture is of an overweight hypertensive smoker, living between the pub and the chip shop. But, you rarely hear that someone “looks a likely candidate for cancer”.

And so it is with the general public. Peoples understanding of risk- lay epidemiology- to give it a formal title, helps determine behaviour. But, with cancer there doesn’t appear to be a common image of a typical high risk person as Sara McDonald (Univ Glasgow) demonstrated at SAPC in St Andrews (Society of Academic Primary Care). If 70% of cancer is preventable by behaviour modification alone, then her Glasgow community have not heard. They recognise the health promotion message, particularly about smoking and sun exposure, but personal experience dominates. They can picture a likely heart disease candidate but are reluctant to think about cancer candidacy. Indeed, you are more likely to hear that someone is the “last person you expected to get cancer”. Greg Rubin (Univ Durham) suggested that we look at raising the profile of the typical cancer victim – rather than simply thinking about individual risk factors. Cancer candidacy is a novel concept and it struck me that our preconceptions are even reflected in the words that we use: We speak about – cancer “victims” but heart attack “candidates”, as if cancer was entirely determined by the fickle hand of fate. It seems we don’t really want to think about cancer candidacy- perhaps one reason is that, like Sara’s patients, we are too scared.

Death is a certainty for us all even if death and cancer don’t always follow immediately. “What would you like to die from”, was the introductory question that made everyone sit up and think when Scot Murray (Univ Edinburgh) championed non cancer palliative care for the BMJ Making a Difference project. It was no surprise, therefore, when Bruce Mason presenting this group’s research, encouraged us to consider end of life conversations much earlier. Most palliative care tends to be precipitated by crisis or imminent death with little prior thought. We need to anticipate patients’ personal preferences as part of advanced care planning before disease progression.

It might help if we begin to think of cancer as a chronic disease. Cancer patients feel ill, but in a footnote in his presentation on validation of functional scales, Gene Feder (Univ Bristol) remarked that these scales could not discriminate between those patients with cancer and those with diabetes. Patients with diabetes feel just as ill.

And, what about future fertility? We might think that, with a diagnosis of cancer and the prospect of treatment, couples may not be thinking about having children in the future. But they do and Scott Wilkes (Univ Sunderland) pointed out that they want professionals to broach the subject and to be given enough information to make a decision. Thinking about living with cancer I was taken by a quote in Paul Sinfields (Univ Leicester) talk from a patient’s wife who said that “while he was focused on living, she was focused on his dying”.

We cannot avoid death. But, both doctors and patients seem to avoid talking about it. There is a death denying culture in many western countries that seems to begin in medical school. Not in South Africa, however, where Alan Barnard (Univ Cape Town), explained how a medical student might clerk six patients their own age with Aids on a Wednesday evening and find just two alive on the ward the next morning. A stark education. Perhaps, we should make death more a part of life.

Domhnall MacAuley is primary care editor, BMJ

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  • Ohad Oren

    Thanks for the enlightening article, Domhnall. What could it possibly be that makes ‘cancer’ such a latent beast, theoretically so hard for experts to decipher, and no less easily retrospectively comprehended? Could it be that the mutation-to-expression time gap obscures the so-called simple molecular processes from being understood on a phenotypic basis? Or that the unique multistep nature of environmental and genetic influences creates an equation too complex to manipulate? But those should not as much interest us if the clinical profile of the cancer patient you are talking about could somehow be defined. To that aim, someone should recognise how to ‘solve’ the next question: where does external factors bear more significance – in the induction of cancerous conditions or rather in metabolic/endocrinic/cardiologic diseases per se? One day, maybe, we will have in our textbooks scales of environmental impacts on various groups of diseases… Sounds imaginary..



  • Claire Jackson-Prior

    This line in the first paragraph makes me shake with rage.
    “With heart disease, our classic picture is of an overweight hypertensive smoker, living between the pub and the chip shop.” It is the idea that anyone can spot illness this way could have cost me my life. I am a 36 year old heart attack survivor who was 8 stone at the time of my MI and had given up smoking, drinking and junk food 6 years previously.
    I think that far from finding a “likely candidate” for any disease, a much better way would be to listen properly to what patients are telling you, and not dismiss possible causes for their symptoms because they don’t fit your preconceived ideas.

  • Geoff Mitchell

    Thanks Domnhall for an enlightening article. To Claire, diagnosis of any medical condition requires working out the probability diagnosis, but not discounting the less likely. I’m glad someone took a good history, but am prepared to bet that when you walked (or were wheeled) in, MI was not the first thing on the doctor’s list of probabilities. Something you said or the way you looked made the doctor notice that your presentation was sufficiently different to other 30-something year old people with chest pain that they looked further afield. Thank goodness.

    That doesn’t stop doctors looking at the chip-eating obese amongst us and thinking they are a heart attack waiting to happen. You are right and so are they.