More than just cancer

The word “cancer” has such implications, and “cancer survivorship” its own associated projections, that these terms run the risk of fully defining the identities of our patients — at least in our eyes as providers.

Most of what we think about in clinic is how to treat the tumor — or how to prevent it from coming back — at all costs, so long as the proposed treatment is felt to be effective, safe, tolerable and desired by the patient. But cancer is an aging-associated disease, and older individuals are not at lower risk for developing, or being affected by, all of the other aging-related diseases that exist.

Two recent studies illustrated this point for me and reminded me that as challenging and statistically complicated as it may be, we need to consider the aggregate of a patient’s overall health risks when thinking about cancer and cancer survivorship. One study was presented by an oncology fellow at Johns Hopkins, Aditya Bardia, at the 2009 ASCO Breast Cancer Symposium. Dr. Bardia looked at cardiovascular risk in patients with early-stage breast cancer treated with aromatase inhibitors, and found that for certain groups of patients, the risk of serious cardiovascular disease was higher than the risk of breast cancer recurrence. This concept is something we don’t often think about in our survivors where cancer is the major — and sometimes, it seems to us, only — issue: that a competing medical risk may be of even more consequence than the cancer itself.

The second study came from Dr. Susan Mitchell and colleagues in The New England Journal of Medicine’s October 15th issue, in which the researchers described the clinical course of patients with advanced dementia. Fully 54% of these patients died within 18 months, leading observers to note that advanced dementia was a “terminal illness” with outcomes similar to “incurable metastatic cancer” or “end-stage heart failure.” I thought of this as I looked at my new patient list for next week, and noted a 90-year-old woman coming to see me for evaluation of a monoclonal gammopathy of undetermined significance, who has been described in her medical notes as someone with long-standing, advanced dementia. I am looking forward to meeting her and her family, though I suspect that I will probably be providing care more as a general internist than an oncologist in this circumstance.

Sometimes, I think, we need to remember that “cancer” isn’t always spelled with a capital “C.”