After 40 years in oncology practice has my experience lived up to initial expectations? My answer is a big YES! On the scientific front the explosion in the understanding of genomics and the defective genes that initiate cancer growth has led to new therapies which target the defective genes and generally have fewer toxic effects than chemotherapy. These so-called targeted therapies are likely to have their main impact on suppressing cancer growth rather than eradicating the disease but prolonged suppression of cancer can be very beneficial and can be compared to the prolonged suppression of the HIV virus in AIDS. Patients with advanced cancer that will ultimately prove fatal are now living several years longer than previously due to better cancer controlling therapies. The rapid progress in the understanding of cancer genetics will ensure there will be a proliferation of new cancer interventions over the next 20 years. Other advances include the identification of defective genes that cause familial cancer which then allows preventive action including screening to be undertaken. Another recent cancer prevention strategy is the use of vaccines against viruses that can cause cancer such as cervical and liver cancers.
On the personal level medical oncology has been a demanding but very rich experience. People with a life-threatening illness go through many traumas as they adjust to the new reality but the human spirit is commonly a powerful force. Through the painful adjustment phase individuals re-set their values and priorities to give more meaning to their remaining life. This change is encapsulated in the concept of spirituality or growth in the human spirit which is now recognised as an important component of the illness experience. We learn so much from patients which is applicable to our own lives. Insights of this type are also very helpful to prevent burnout in health professionals. If the view of oncology is purely the medical perspective of the disease and treatment, the accumulated burden over years of practice can be crushing.
Relationships with patients and families is the most fascinating part of medicine, and oncology in particular. Patients with serious illness recognise this and frequently will mend relationships and say things to families that were previously unsaid. A good health professional-patient relationship is also vital for those with cancer. Doctors appreciate the opportunity to get to know their patients over time as this allows much better understanding of the people that we serve, however, it also allows us to finesse the partnership that is the basis of good medicine. I have learnt the value of listening, being ready to compromise and being honest. Honesty includes saying, when appropriate, that you just don’t know. The fully formed doctor-patient relationship generates respect in both directions. It usually generates fondness, but not always so as some patients can remain very challenging. Even in these circumstances, respect is fundamental. Developing so many relationships with inspiring humans who suffer from cancer is the greatest reward and this carries many rich memories. Of course it also makes it harder to cope with the death of those who are not cured. The loss of patients can be softened for the doctor by both sides being open about the nature of the illness and by maintaining the professional relationship until death. In a sense this allows us to express a professional goodbye and so round off the relationship. This is very important for our sanity!
It is a pity that our insights into the important things in life seem to come in the more mature years or when grave threats occur. My understanding of the power in the therapeutic relationship grew in the second half of my career but I have tried to communicate this importance to medical students and younger doctors with variable success. Looking back I realise that my initial instincts about oncology were correct but my deeper understanding of good medical practice and the satisfaction this delivers has been thanks to the privilege of working with so many who face the challenge of cancer and, for many, their own mortality.
Dr David Perez is a recently retired medical oncologist at Dunedin Hospital and Director of the Early Learning in Medicine Programme, Faculty of Medicine, University of Otago (Dunedin, New Zealand).
Read the first part of David’s article about his career in medical oncology here.