Cancer patients deserve to know the facts - a layman's response

I refer to Professor Joseph A. Muscat's letter ("Cancer and Alternative Medicine", The Sunday Times, August 5) and to Professor Albert Cilia-Vincenti's article ("Medicine's struggle against cancer", August 19).

At the outset, Professor Muscat cautions readers "not to swallow some of the widely off-the-mark statements about cancer, its diagnosis and treatment". I will attempt to rebut each of the issues that Professor Muscat raised.

First, Professor Muscat labels integrative medicine as "pie in the sky". I assume that to him alternative complementary medicine (CAM), even more so integrative medicine, is an affront, since it assumes that conventional medicine is just one among other possible philosophies, rather than being truly scientific medicine. Not surprisingly, he fails to acknowledge CAM as being something positive in its own right. There are a number of experienced and qualified proponents and practitioners of CAM in Malta who can attest to what I write in respect of this issue but, regrettably, they have opted to keep their incomprehensible silence.

Obviously, Professor Muscat does not and probably will never belong to that growing number of tomorrow's doctors for whom boundaries will not be drawn in as hostile a manner as they have been in the past. He seems to be oblivious to the fact that the integration of alternative medicine into conventional medicine has increased the mutual trust of both practitioners, and long-standing barriers have begun to be torn down. Once professionally derided and ostracised by conventional doctors, osteopaths, naturopaths, chiropractors, and holistically oriented general practitioners, are finding a warmer reception at institutions of higher learning in some European countries and the United States.

Medical Council's ruling

Professor Muscat has for years expressed his opinion in The Sunday Times regarding the composition, nature and functions of the Malta Medical Council. I would be interested to learn from him whether he perceives the UK General Medical Council as too avant-garde in permitting a medical practitioner to practise his/her profession concurrently with another health care profession, assuming of course that the medical practitioner is qualified as an alternative health practitioner.

Does Professor Muscat give his unqualified support to the Malta Medical Council's current ruling that "under no circumstances would it permit a medical practitioner or dental surgeon to practise his/her profession concurrently with another health care profession"? (Medical Council report, 2005). I assume he does.

Professor Muscat asks if it is rational that proponents and practitioners of alternative medicine "should expect scientific medicine to test their therapies for them whatever they may be, mistletoe, mushroom or whatever". My hope is that the government will see the urgent need to conduct full clinical trials of some of the more promising complementary and alternative treatments for cancer. I wonder whether CAM proponents and practitioners have an opinion on this.

Secondly, Professor Muscat asserts that human error by medical and nursing staff involved in the care of cancer victims "has existed and will go on even in centres of excellence..." I refer readers to part 2 of my article (July 8) which paints a statistically proven, albeit depressing picture of mostly preventable medical injuries as opposed to human error malpractice.

Additionally, I wrote: "My last five years doing counselling work and supporting my wife in her struggle against cancer lead me to believe that Malta is no better statistically than any other country when it comes to medical errors and negligence". Discerning readers would be interested to know of any programme the Department of Health runs which monitors adverse events, errors and near misses along the entire spectrum of care delivery in our public and private hospitals. Why is it that the Department of Health has opted to keep silent in this respect? Are the authorities concerned aware that their silence speaks volumes?

Professor Muscat's experience in the UK and in Malta leads him to believe that lack of ordinary clinical acumen contributes to a wrong diagnosis or delayed diagnosis of cancer. Is this why he demonstrates a complete lack of enthusiasm for the introduction of a PET scanner at our state-of-the art Mater Dei Hospital? Readers would be interested to learn from him whether a PET scanner, irrespective of its costs, has a cutting edge over other highly rated and effective diagnostic tools when it comes to the detection of cancer. If it does, why does he not advocate its provision?

Thirdly, Professor Muscat begs to differ from Dr Moss's opinion on radiotherapy. Dr Moss is by no means a mindless iconoclast on the issue of radiotherapy. He simply wants to alert cancer patients to the real dangers inherent in radiotherapy prior to giving their informed consent to treatment. Indeed, radiotherapy can be a useful treatment modality in certain cancers, as Professor Muscat so rightly put it, and it does require "a high standard of expertise in its use as it is a powerful weapon and may cause harm if used inexpertly".

However, on what basis would Professor Muscat refute Dr Moss's claim that exposing bone to radiation can result in four major types of complications: necrosis (a type of cell death), fractures, severe alterations in bone growth, and radiation-induced cancers? Moreover, Professor Muscat seems to be out of touch with recent research on the link that exists between radiotherapy and heart problems for women who have had breast cancer.

A major new trial involving 4,414 women who had radiotherapy following treatment for breast cancer has confirmed that the risk is as real as ever. Nearly 22 per cent of the women suffered heart disease following therapy. The risk was far greater in those who had radiotherapy to the surrounding healthy lymph nodes, which is common practice in order to stop the spread of the cancer. The risk tripled among women who smoked, or who had smoked at some time (Journal of the National Cancer Institute, 2007; 99: 340-1).

Fourthly, according to Professor Muscat, conventional medicine never stood in the way of the 'pro-active' patient and a consultant welcomes sharing responsibility for a choice of treatment with a patient who is willing to participate, which is not often the case". I wonder whether Professor Muscat is willing to share with readers his perceptions of why patients often are not willing to participate.

My experience as a patient in Malta and abroad, and, even more so, as a guardian ad litem and reporting officer in the UK, leads me to believe that there are highly-skilled and dedicated medical doctors who conscientiously keep medical records, are always ready to attentively listen to their patients and patiently explain to them all the possible side-effects of a particular diagnostic tool or treatment. Regrettably, I have also come across a significant number of medical doctors who are presumptuous or arrogant, flippant or bossy with patients as well as nursing staff.

At the end of his letter, Professor Muscat comments: "However a patient and his or her family cannot expect the health authorities to refer them abroad to a unit of their choice for alternative therapy free of charge, at the expense of the local taxpayer. And even less should a patient expect to be referred abroad for alternative therapy free of charge, because he or she feels more at home and more comfortable in the country of his or her choice". Nowhere in my article did I suggest that patients should be allowed to go abroad for alternative treatment free of charge or at the expense of the local taxpayer.

Professor Muscat should know that hyperthermia and Temadol are not classified as alternative therapy treatments. Hyperthermia is an innovative radiation therapy and Temadol is a recognised drug for the treatment of melanoma. Professor Muscat's implicit comment that my wife expected the health authorities to refer her abroad to a unit of her choice for alternative therapy simply boggles my mind.

It would help if Professor Muscat were to be more diligent in what he writes and not to make such wide of the mark statements. Moreover, he should keep himself updated with recent rulings of the European Court of Justice regarding EU citizens' right to seek certain provisions of health care in member states other than their own.

Chemotherapy and mammography

There are a number of key issues that Professor Cilia-Vincenti and I seem to agree upon. First, most cancers have been very resistant to medical efforts, be it chemotherapy or radiotherapy. Secondly, environmental carcinogens, particularly in our urban areas, adversely affect the health of our population. Thirdly, a holistic and, therefore, a more integrative approach would be more beneficial to cancer patients.

It is admirable of Professor Cilia-Vincenti to openly support complementary medicine and, therefore to run the risk of becoming some of his medical colleagues' object of lively ridicule for his unorthodox views.

Professor Cilia-Vincenti takes me to task on two specific issues. First, he is concerned that my article leaves one with the impression that "practically nothing has been achieved in conventional medicine's struggle against cancer these last 50 years". Secondly, he is disturbed by my "particularly scathing" comments on mammographic breast screening.

It is right to say that in the first part of the article entitled "Are we winning the war on cancer?" I unequivocally stated that I was not at all convinced that chemotherapy, as one of the modalities of treatment, was bringing about "a veritable revolution in the survival of victims from cancer" (Professor M. Cauchi, The Times, May 3); I did however clearly state that a quiet but heartening evolutionary process is taking place in the war on cancer.

For instance, I pointed out that chemotherapy had favourable results in certain types of cancer, that genetics seems to be at the forefront of cancer research, and that the Human Genome Project offers great hope to patients.

Moreover, in the second part of the article entitled "Screening and diagnostic methodology", I clearly stated that conventional medicine offers a number of diagnostic tests, some of which can be quite accurate and require sophisticated equipment - I advocated the provision of a PET scanner which would greatly enhance our oncology programme and put it at the cutting edge in the diagnosis and management of cancer patients. I very much doubt whether the Oncology community in Malta would disagree with my opinion.

Finally, part 3 of my article entitled "The role of integrative medicine" (July 15) emphasised the need for both conventional and complementary medicine to join forces in the best interest of cancer patients.

I want to emphasise the point to Professor Cilia-Vincenti that references to mammography throughout my article were geared towards mammographic screening and not mammographic diagnosis. There is no argument about the usefulness of mammography as a diagnostic tool.

I am not intent on knocking mammographic screening or advocating the wholesale abandonment of screening mammography. I fully subscribe to what Dr Moss has to say on this issue: "While I do not want to discourage women from being screened for breast cancer - on the contrary, I believe that vigilance and early detection are extremely important - I do feel it is vital for women to have a full understanding of the procedure and realistic expectations as to what it can, and, cannot do. This is the true basis of informed consent."

My extensive readings lead me to believe that there is no consistent, substantial scientific evidence that regular mammography screening results in a significant reduction in mortality for breast cancer.

The photo with the caption: "Mammography reduced breast cancer in women aged 40-70" which appeared in Professor Cilia-Vincenti's letter, is misleading and flawed. The usefulness of the study that he refers to and the validity of its conclusions are undermined, in my view, by the fact that the sample population spanned an entire age range, from 40-70 years of age. Additionally, no attempt seems to have been made to separate women into different age groups, that is, the pre- and post-menopausal women. This was a particularly crucial omission since the natural history of the disease varies widely in different age groups, and it is precisely about pre-menopausal women around whom the debate rages.

Professor Cilia-Vincenti writes that we are in agreement about being cautious with too many mammograms in young women at high risk of developing breast cancer; hence, he refers to the British National Health Service recommendation for MRI in this small group of women. I would like to add that breast MRI is seeing enormous growth rates; for instance, guidelines from the American Cancer Society stipulate that all women with a lifetime-risk of only 20 per cent are to receive a breast MRI for early detection.

Interestingly enough, a study in The Lancet (Vol. 370, August 11) states that MRI is substantially more accurate than mammography in diagnosing very early stages of breast cancer. Up to now MRI was thought to be hardly suited for the detection of ductal carcinoma in situ (DCIS). Christianne Kuhl, Professor of Radiology and Director of the Division of Oncologic Imaging and Interventional Therapy at the University of Bonn, states that this study demolishes a whole series of textbook dogmas.

According to Professor Kuhl, it was always said that MRI was unable to find early stages of breast cancer in milk ducts. The study shows the opposite is true. Additionally, it was also stated that MRI often leads to 'false positives', that is, often causes 'false alarms'. The study shows MRI yields fewer 'false positives' than mammography. The study also concludes that until now it was assumed that MRI was only necessary for early detection of breast cancer in women with an increased risk of breast cancer.

Many of the participants had taken part in the study as part of the perfectly normal cancer check-up. The conclusion of the Bonn research team is that MRI can improve the diagnosis of very early stages of breast cancer significantly, not simply with high-risk groups, but with all women. I sincerely hope the Oncology Department in Malta and Action for Breast Cancer Foundation will heed this study.

I am in agreement with Professor Cilia-Vincenti's comment that the cause of the vast majority of breast cancer is not X-rays but a combination of inheritance and oestrogen and insulin levels. However, I believe a word of caution about X-rays is vital. A comment made by Etienne Grech, president of the Society Medical Radiographers, and entitled "Excessive use of CT scans" (The Times, August 10) is quite revealing: "In a research study performed last year by one of our members, the majority of responding physicians surveyed were unable to quantify the radiation dose yielded in such examinations and other associated risks". My question is: Quis custodiet ipsos custodes? Who guards the guardians? Is it the role of the Medical Council to guard patients and to issue guidelines to our physicians?

Investing in a PET scanner and in a breast MRI is a political and not a medical decision. It is quite likely that the government is satisfied in having a state-of-the-art Mater Dei Hospital without having to invest in such potentially life-saving equipment. Regrettably, the MLP's Shadow Minister of Health's position on this issue has been one of deafening silence. I assume that these potentially life-saving diagnostic tools, very much like the much needed radical reform of the Medical Council, are not on his agenda. He owes an unequivocal explanation to cancer patients as to what his designs are in this matter. Cancer patients deserve to know the facts.

Mr Muscat worked as a guardian ad litem and reporting officer for the UK's High Court and London's Family Proceedings Courts.