Conventional medical oncology: descriptions, advantages, and shortcomings
“Response to treatment” versus “quality of life” versus “survival time” versus “cost-effectiveness”:Four main criteria are used for the assessment of anti-cancer treatments:
1. Response to treatment
2. Quality of life versus adverse effects:
3. Survival time
4. Cost-effectiveness
The ideal treatment would 1) produce a measurable and quick response to treatment, 2) maintain or enhance the patient’s quality of life with minimal short-term and long-term adverse effects, 3) significantly prolong disease-free survival time and maximize the patient’s lifespan by optimizing health and preventing other diseases (all-cause mortality and morbidity), and 4) be financially affordable to patients, insurance companies, and government supported healthcare services.
Maximize: | Response to treatment Quality of life Disease-free survival time Life span |
Minimize: | Adverse effects All-cause mortality and morbidity Financial cost |
In this manner of constructing “ratios” all treatments are evaluated by terms such as:
· Cost-effectiveness:
· Risk-benefit ratio:
· Therapeutic index:
· Incremental cost-utility ratios:
· Quality-adjusted life-year
Many allopathic oncology treatments produce “responses” without increasing survival, and the majority of these significant/insignificant responses are achieved only at a huge financial cost and decimation of quality of life. Increased “survival time” is generally what motivates cancer patients to seek treatment. People generally want to live as long as possible, provided that they can do so without making too many sacrifices, such as financially impoverishing their families to pay for treatments, or reducing their quality of life by suffering from the side effects of treatment.
“Quality of life” refers to the patient’s comfort, his/her ability to lead a normal life, to pursue hobbies, activities, occupations, interests, and to participate in family and social life. Most allopathic oncology treatments reduce or annihilate quality of life for the majority of patients who undergo chemotherapy, surgery, or radiation.
“Response to treatment” generally means that the tumor shrank; reducing the size of the tumor can be important in situations wherein a large tumor is compressing vital structures such as the brain or internal organs, but otherwise “response” pales in comparison with the importance of quality of life and survival. People want to live strong and live long; most people would not be too concerned to learn that they have a small mass of nonfunctional cells in their body as long as this small mass of nonfunctional cells (ie, “tumor”) was not causing them any harm, that it was not adversely affecting their health or lifestyle, and that it was not going to shorten their lives. Thus, shrinking the tumor (ie, achieving a “response”) is truly subordinate to increasing survival time and maintaining quality of life.
The relative failure of cancer research to produce meaningful improvements in quality of life and survival for cancer patients is well established. Take for example this brutally honest editorial from the peer-reviewed medical journal written by cancer specialists - The Oncologist.
Beware the Medical-Industrial Complex.
Stevens CW, Glatstein E.
Department of Radiation Oncology, University of Pennsylvania Philadelphia, Pennsylvania, 19104, USA . Oncologist 1996;1(4):IV-V
". we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex." Dwight D. Eisenhower, 34th President of the United States (1953-1961). Farewell Address, January 17, 1961 . If Ike were with us today, he might well expand his views on power and influence to include modern American medicine. The corporatization of health care in the United States has moved rapidly in recent years. Physicians are now in a position that requires us to adapt to an increasingly Darwinian existence. Years of training to be "rugged individualists" pushing the frontiers of medical knowledge have not equipped us to fight corporate battles, nor to justify our treatment decisions to bean counters. When the most important consideration becomes the bottom line, then innovation, creativity, and research diminish in importance. They will, in fact, be selected against because they cost money. Up to now, these have been the hallmarks of American medicine, and we must strive to maintain our position of American leadership in biotechnology. New developments in cancer treatment include expensive technological "bells and whistles" which physicians must ultimately evaluate objectively, despite lush advertisements from companies with obvious vested interests, and authoritative testimonials from biased investigators who presumably believe in their own work to the point of straining credulity and denying common sense. The 3-D image that was created by a computer may look beautiful (and cost accordingly), but it is hard to believe that it can fundamentally change the outcome of patients when it does not add any new data that bear on basic issues. For example, where is the exact edge of the tumor? If one pays through the nose for increasing precision where there is no new accuracy, the purchase appears less attractive, perhaps, than the hype of the salesman or the enthusiasm of a neurosurgeon or a "stereotactic" radiation oncologist (showing biased data, if any at all). For radiation therapy, the 20th century has largely represented progress by creating larger, higher energy machines for treatment. Now, with the 21st century on the horizon, x-ray treatment parameters have probably been optimized over the past 10 years or so. We see no obvious advantage in an x-ray beam beyond about 18 MeV, and none for electrons beyond 20-25 MeV. Exotic particles such as protons, neutrons, and negative pions, though expensive and difficult to deliver, have not yielded yet significant gains in either local control or survival. A variety of new afterloading machines, such as pulsed high dose rate machines, have also been developed with no clear biologic advantage over more standard remote afterloaders. Thus, new equipment will be exploiting issues of convenience, efficiency, and increased throughput (translate: economic improvement, not biological superiority). Today's technology is vastly ahead of our biologic understanding of malignant cells. Our true challenge for the 21st century is to understand the biology of malignant cells and to bring our technology to bear on the biological aspects of cancer. To improve results, cellular manipulations of some sort will probably be necessary. Perhaps these will be mediated through gene therapy, although the manipulation of some genes, to the exclusion of all others, in only tumor cells and in all tumor cells may be a biological challenge beyond our limitations. One is reminded of another time, a decade or two ago, when some tumor immunologists were predicting monoclonal antibodies would soon replace other modalities. Eventually, over time, the immunologists began to appreciate the enormous adaptability that cancer cells possess; the cells are much more than passive receptacles of antigens simply waiting to be destroyed by antibodies. Drugs which affect the function of specific oncogenes, such as the farnesyl transferase inhibitor effect on ras genes, are also quite promising. Clearly, however, there are not "magic bullets" for most cancers. The effects of gene manipulation on patient outcome, if any, are likely to be found only in the setting of combined modality therapy. The most promising clinical research from the last decade or so reinforces the utility of a combined approach in treating cancers. Unfortunately, combined treatments and the development of new combined treatments are expensive. In today's world of corporate medicine and managed care, academic centers are under considerable pressures. They are perceived as being too expensive, and thus they are in danger of being shut out of contractual arrangements with third-party representatives. If these centers are to survive, they must reform themselves: One, they must establish meaningful relationships with community hospitals and community physicians. Two, the academic programs must learn to minimize charges and deliver a true multidisciplinary service to patients in an efficient way. Three, the centers must learn to invest wisely in new technologies that community hospitals cannot and will not be expected to support. This "wisdom" refers to selection of technology that truly may have impact on the outcome of patients' lives by early detection or by treatment. The euphoria associated with projected gains of some investigational treatments can be misleading: randomized prospective trials have shown in the past that postoperative radiation following a complete resection of lung cancer, breast cancer, or rectal cancer adds a major improvement to local control, but with relatively little improvement in survival. How many times will it be necessary for companies and self-impressed investigators to rediscover this particular wheel? We must remember that every new therapy costs money, so we must focus our research time and money in promising areas. If cost is allowed to be the most important mitigator of health care, research as we know it will end. The relative lack of new therapies means that some people will die prematurely because of our lack of foresight. As scientists, we must be seen as providers of a value-added product. Improvement in cancer cure rates has been frustratingly slow. We work against a clever, tenacious adversary - both in the clinic and in the corporate board room. It is our responsibility to tout our accomplishments, admit our failures, and provide progressively better basic and clinical research with an eye toward future improvements in outcome. We must not be seen as yet another special interest come to drink at the well of public spending, but as advocates for the public good. If we fail to become important to those who control medical spending, we will be unable to make any important long-term contribution to those who matter most - our patients.
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A decade of breast cancer clinical investigation: results as reported in the Program/Proceedings of the American Society of Clinical Oncology.
Chlebowski RT, Lillington LM.
Division of Medical Oncology, Harbor-University of California at Los Angeles Medical Center, Torrance 90509.- J Clin Oncol 1994 Sep;12(9):1789-95
PURPOSE: To test the hypothesis that clinical research results have driven changes in recent breast cancer management recommendations. METHODS: All breast cancer abstracts in the Program/Proceedings of the American Society of Clinical Oncology (ASCO) from 1984 to 1993 were prospectively reviewed in 31 areas and categorized by study type, study question, whether statistical significance was claimed, and whether the abstract was presented. RESULTS: Of 1,372 abstracts, 54% reported on prospective clinical trials (PCTs) and 17% on randomized clinical trials (RCTs). The total number of published abstracts progressively increased (from 87 in 1984 to 221 in 1993) and author citations nearly quadrupled (from 430 in 1984 to 1,642 in 1993, P < .01); however, RCTs have come to represent a smaller proportion of reports: 37% (33 of 89) in 1986 versus 10% (22 of 221) in 1993 (P < .001). The size of adjuvant-therapy RCTs has progressively increased (mean +/- SEM subjects/trial, 237 +/- 43 in 1984 to 874 +/- 374 in 1993), but has remained small in advanced-disease RCTs (mean +/- SEM subjects/trial, 145 +/- 25 in 1984 to 146 +/- 34 in 1993). For adjuvant therapy, 14 of 90 RCTs (with 51,207 patients) reported a significant (P < .05) survival benefit for investigational therapies (16%). For advanced-disease therapy, only three of 141 RCTs (with 26,281 patients) reported a significant (P < .05) survival benefit for investigational therapies (2%). Randomization was rarely used in trials of dose-intensity with blood-product support (zero of 86 trials) or locally advanced disease. CONCLUSION: For breast cancer ASCO abstracts in the past decade, we determined the following: (1) adjuvant trials have not infrequently supported study hypotheses; and (2) advanced-disease trials have consistently failed to identify new approaches with a significant impact on survival. These results suggest that a critical process evaluation of current policy and procedures involved in directing breast cancer research is warranted, especially for strategies in advanced disease.
“Cancer” refers to a group of disorders generally characterized by 1) uncontrolled cell growth and proliferation, and 2) “spreading” (metastasis) of these abnormal cells to different locations within the body. Ultimately, cancer cells can cause injury and death by 1) damaging vital organs such as the brain and liver and 2) by causing malnutrition and starvation (cachexia).
The medical-allopathic approach (used by most MDs and medical oncologists) relies almost exclusively upon the following external, passive, limited, toxic interventions of surgery, radiation, and chemotherapy. I describe these “treatments” as external, passive, limited, and toxic for the following reasons:
External—Conventional oncology treatments of surgery, radiation, and chemotherapy appear to erroneously assume that the cancer just arose spontaneously (as if from “outside” the body) without influence from the rest of the body. This is clearly illogical and is not in accord with any research whatsoever. Cancer is an “internal” problem, which only manifests if several of the body’s anti-cancer mechanisms have failed. These mechanisms are manifold, but include the following for the sake of this discussion. Conventional cancer treatments fail to address these issues.
· Detoxification
· Immune function and immune surveillance against cancer cells.
· Regulation of cell adhesion
· Regulation of apoptosis (programmed cell death) and its induction by safe, natural, and non-toxic substances
· Regulation of differentiation by natural substances
Passive—Treatments that discourage the patient from taking an active role in his/her healthcare foster the illusion that the patient is the “victim” and the doctor is the “savior” and this is often reflected in popular descriptions of people with cancer as “cancer victims.” This perspective robs patients of the empowerment they need and deserve in order to take an active and participatory role in their healthcare. This perspective also fails to acknowledge that patients have many powerful options and interventions that they can employ to help themselves recover from cancer and have reduced toxic effects of their chemotherapy/radiation treatments.
Limited—Traditional oncology treatments only target the cancer cells. These treatments fail to address the underlying mechanisms that lead to the development of cancer in the first place, therefore leaving the patient susceptible to having a recurrence of cancer.
Toxic—Radiation and chemotherapy are toxic treatments with significant and often life-threatening side effects. Common and serious “side-effects” of allopathic cancer treatment include:
1. Debilitating fatigue
a. Inability to pursue hobbies, interests, and occupation
b. Inability to care for oneself and family and to participate socially
2. Anemia
3. Hair loss
4. Weight loss
5. Reproductive/sexual failure (temporary or permanent)
6. Nausea
7. Vomiting
8. Renal failure
9. Swelling and edema
10. Cancer
Surgery to remove cancerous tissue
· Advantages:
o Can theoretically lead to cure by removing cancer cells.
o Allows passivity on the part of the patient, ie, the patient does not have to assume significant responsibility for his/her own care.
o Allows expediency on the part of the physician, ie, the doctor does not have to get overly involved with the patient to learn the intricacies of the individual patient and to therefore spend time customizing a treatment plan for that individual patient.
· Disadvantages:
o Surgery almost never allows removal of all cancer cells, and can therefore lead to a false sense of security if used as the only treatment. Additionally, surgery liberates cancer cells from the tissue and increases the number of cancer cells in the blood.[1]
o Surgery for cancer always involves removing body tissue that surrounded the tissue to provide a clean “margin” around the previous location of the tumor. Therefore, some healthy tissue is lost, which can result in functional or cosmetic defects.
o Reliance on this “external” and “limited” type of treatment does not address the underlying issues which contributed to the development of cancer in the first place in that patient, and it does not do anything to either prevent new cancer from developing or to prevent the remaining cancer cells from “taking root” and establishing new tumors.
Radiation to destroy cancer cells
· Advantages:
o Kills (some-most) cancer cells.
o Allows passivity on the part of the patient, ie, the patient does not have to assume significant responsibility for his/her own care.
o Allows expediency on the part of the physician, ie, the doctor does not have to get overly involved with the patient to learn the intricacies of the individual patient and to therefore spend time customizing a treatment plan for that individual patient.
· Disadvantages:
o Radiation almost never allows removal of all cancer cells, and can therefore lead to a false sense of security if used as the only treatment. Radiation is applied to only a localized area of the body; cancer cells outside of the field of treatment are not affected.
o Radiation for cancer always involves radiating body tissue that surrounds the tumor. Therefore, some healthy tissue is lost or injured, which can result in functional or cosmetic defects. Skin burns are almost to be expected with radiation treatment.
o Reliance on this “external” and “limited” type of treatment does not address the underlying issues which contributed to the development of cancer in the first place in that patient, and it does not do anything to either prevent new cancer from developing or to prevent the remaining cancer cells from “taking root” and establishing new tumors.
o Exposure to radiation is a known cause of cancer. For example, women with uterine cancer who are treated with radiation have an increased risk for later developing leukemia.[2] Common sense leads us to question the use of a cancer-causing treatment as a therapy against cancer.
Chemotherapy with various drugs and chemical agents to essentially poison the cancer cells
· Advantages:
o Kills (some) cancer cells if they are sensitive to the drugs being used.
o Allows passivity on the part of the patient, ie, the patient does not have to assume significant responsibility for his/her own care.
o Allows expediency on the part of the physician, ie, the doctor does not have to get involved with the patient to learn the intricacies of the individual patient and to therefore spend time customizing a treatment plan for that individual patient.
o Disadvantages:
o Chemotherapy does not always allow removal of all cancer cells, and can therefore lead to a false sense of security if used as the only treatment.
o Chemotherapy is applied to the entire body. Therefore, tissues and organs that are not involved by the cancer are subjected to the same toxic treatment as if they were cancerous. This can lead to so-called “side effects” which can be serious and fatal, which is paradoxical since the goal of treatment should be 1) the preservation of function, 2) enhancement of the quality of life, and 3) the prolongation of the patient’s life. Systemic toxic effects are almost universal with the use of chemotherapy and extend beyond fatigue and hair loss to include serious complications such as kidney failure. Acute renal failure is associated with chemotherapeutic drugs such as carboplatin and cisplatin.[3]
o Reliance on this “external” and “limited” type of treatment does not address the underlying issues which contributed to the development of cancer in the first place in that patient, and it does not do anything to either prevent new cancer from developing or to prevent the remaining cancer cells from “taking root” and establishing new tumors.
o Many “chemotherapy” drugs are known to cause cancer. Common sense leads us to question the use of a cancer-causing treatment as a therapy against cancer. Cancers that result from previous chemotherapy are called “secondary malignancies” or “secondary cancers.” For example, some women with ovarian cancer treated with platinum-based chemotherapy will later develop leukemia.[4] [5] A 1996 article published in The British Journal of Hematology[6] notes that secondary cancers associated with previous use of platinum-based chemotherapy (ie, carboplatin and cisplatin) are becoming more common, and that the overall risk to patients treated with these drugs is between 2% and 10%. Many patients are not informed of this risk of secondary cancer before they are treated with chemotherapy, and it is likely that many patients would refuse treatment if they knew that they faced an increased risk of developing cancer as a result of the treatment used to treat their cancer.
In contrast to the medical-allopathic approach which is external, passive, and limited, and toxic, natural treatments are:
Internal—Many natural treatments address the fundamental underlying problems inside the body that lead to the development of cancer in the first place, thereby helping to eliminate the current cancer and also helping prevent the development of future cancers.
Active—Natural treatments empower you to take an active role in your health by making healthful and positive changes in your diet, lifestyle, supplementation, and social relationships.
Comprehensive—Natural treatments often address a full spectrum of health issues that predisposed the patient to cancer. Rather than relying upon a single treatment or mechanism of action, natural treatment uses several different treatments that work together to make the body as a whole work better.
Non-toxic—Most natural treatments have not toxic effects whatsoever. In fact, they often help to alleviate other health problems in addition to helping the patient become free of his/her cancer.
Many natural treatments (either used alone or in selected combination with chemotherapy and radiation) have been proven in peer-reviewed medical research to:
o Reduce side effects of other toxic-chemical-allopathic treatments.
o Improve quality of life.
o Cause tumors to shrink or disappear.
o Significantly prolong life.
Several natural treatments have been proven to be more effective than chemotherapy for the treatment of certain cancers.
Mind-body research in psychooncology.
Greer S. St Raphael's Hospice, Sutton, UK.
Adv Mind Body Med 1999 Fall;15(4):236-44
The biomedical model of disease, though powerful, does not explain all known facts about cancer. It is argued that a broader theoretical framework which includes psychosocial factors is needed. There is empirical evidence that a hopeless/helpless coping style is associated with unfavorable disease outcome in patients with certain cancers. The converse, namely a link between an active, fighting spirit coping style and favorable disease outcome, is under-researched and less clear-cut. The delineation, measurement and psychophysiology of positive states of min1d have been sorely neglected. This is a promising area for future research. Psychobiological mechanisms of possible relevance to cancer are considered in terms of psychoneuroimmunology. Despite formidable theoretical and methodological problems, some progress is being made. Recent evidence indicates that psychotherapeutic intervention can augment natural killer cell activity and lymphokine-activated killer cell activity in patients with malignant melanoma and with locally advanced, nonmetastatic breast cancer respectively. These challenging findings, if confirmed, have major implications for our understanding of mind-body interactions in patients with cancer.
Feelings of empowerment are associated with an increased probability of survival and favorable outcome. “Psychotherapeutic intervention” can improve the function of the immune system in patients with cancer.
A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients.
Speca M, Carlson LE, Goodey E, Angen M.
Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board
Psychosom Med 2000 Sep-Oct;62(5):613-22
OBJECTIVE: The objective of this study was to assess the effects of participation in a mindfulness meditation-based stress reduction program on mood disturbance and symptoms of stress in cancer outpatients. METHODS: A randomized, wait-list controlled design was used. A convenience sample of eligible cancer patients enrolled after giving informed consent and were randomly assigned to either an immediate treatment condition or a wait-list control condition. Patients completed the Profile of Mood States and the Symptoms of Stress Inventory both before and after the intervention. The intervention consisted of a weekly meditation group lasting 1.5 hours for 7 weeks plus home meditation practice. RESULTS: Ninety patients (mean age, 51 years) completed the study. The group was heterogeneous in type and stage of cancer. Patients' mean preintervention scores on dependent measures were equivalent between groups. After the intervention, patients in the treatment group had significantly lower scores on Total Mood Disturbance and subscales of Depression, Anxiety, Anger, and Confusion and more Vigor than control subjects. The treatment group also had fewer overall Symptoms of Stress; fewer Cardiopulmonary and Gastrointestinal symptoms; less Emotional Irritability, Depression, and Cognitive Disorganization; and fewer Habitual Patterns of stress. Overall reduction in Total Mood Disturbance was 65%, with a 31% reduction in Symptoms of Stress. CONCLUSIONS: This program was effective in decreasing mood disturbance and stress symptoms in both male and female patients with a wide variety of cancer diagnoses, stages of illness, and ages. cancer, stress, mood, intervention, mindfulness.
Meditation can reduce negative symptoms and increase energy in cancer patients.
More details, along with substantiation with medical research, will be posted on this page in the near future.
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