Just wondering

I’ve been working on a presentation — and in between bouts of productivity, I’ve been cleaning up the office, flipping through and recycling old journals and tearing out the occasional interesting article.

I’m not sure why this one happened to catch my attention, but I spent a few minutes reading through the report by Allin et al in the May 1 issue of the Journal of Clinical Oncology about the association between baseline C-reactive protein and both incident cancer as well as survival in patients with cancer. The last sentence of the conclusion in the abstract may have been what drew me in: “Elevated levels of baseline CRP associate with early death after a diagnosis of any cancer, particularly in patients without metastases.” As I read through the article, I found this conclusion intriguing but mostly provocative — without much additional information about these patients available, it was hard to know exactly what this meant.

But it got me thinking about an old question: Why do patients with cancer die? As I remember patients I’ve treated, or recall articles in journals or presentations at meetings, my initial thought is that it’s because the tumor has stopped responding to treatment. But while this is something that invariably happens, and is the basis for why we use certain treatments in preference to other treatments, it’s not really a satisfying answer, is it? A quick review of PubMed for causes of death in cancer patients (a deceptively difficult search, as it turns out) turns up a series of studies from the mid 1970s and early 1980s, when investigators tried to look at this question via autopsies and other means. The proximate causes of death, as we know from our clinical experience, are often not the direct physical consequences of a primary tumor or a metastatic deposit. Instead, it’s usually something else — weakness, wasting (the cancer anorexia-cachexia syndrome plays a large role in many patients) — that ultimately leads to the body becoming overwhelmed — by infection, for example, or something else.

I daydream sometimes, like Alice through the looking glass, that some day one of us will realize or discover a fundamental insight that completely turns on its head the way we currently think about cancer and its treatment. Maybe this might be a common pathway of disease progression that leads to a therapy that increases survival for patients with all sorts of different cancers. Wishful thinking, maybe — but we can always hope.