Bernard M. Jaffe, MD
Professor of Surgery
Department of Surgery
Tulane University
School of Medicine
New Orleans, LA

In last month's Surgical Rounds editorial, "The vertical hour," I focused on the surgeon's role in reporting to his or her patients following extirpative procedures for malignancy. This editorial extends those observations and deals with the inevitable question from a terminal patient, "How long do I have to live?"

Coincidentally, the evening after I completed "The vertical hour" editorial, I attended a dinner party at which a very good friend asked me about the survival potential of his colleague who had carcinoma of the esophagus and liver metastases. I pointed out that no physician can accurately predict longevity but that his colleague likely would not live for very long, particularly since the colleague could feel the enlarging epigastric tumor masses. My friend reported that this ill colleague was undergoing chemotherapy and feeling particularly terrible. I made the mistake of commenting that I would not have recommended such treatment, both because of its futility and the misery it would predictably inflict on the patient. It seemed to me that this was the ideal circumstance for the old adage "a bottle of scotch and a fishing pole."

Patients who have unresectable or metastatic lesions face a difficult quandary: whether to accept or decline chemo/radiation therapy. If objective data document likely improvement in the patient's quality of life or significantly increased longevity, there is no real decision. On the other hand, it is far tougher if the survival statistics are equivocal or negative. Rejecting antineoplastic treatment signals the acceptance of one's fate and initiates a countdown. Family members are loath to accept this option, even if it is in their loved one's best interest. Medical and radiation oncologists are generally even more biased and will aggressively advocate a treatment regimen. Their arguments sound very convincing, particularly to vulnerable and suffering patients.

It takes a special kind of person to be a medical oncologist. Watching so many patients die, it may be inevitable that they become hardened. Their understandable response is to offer more and more medication. The late, great Dr. Robert Zollinger had a notable name for these specialists. He proudly called them "ambulatory morticians" and argued that they would give the last dose of chemotherapy to patients in their caskets. While such a statement is clearly absurd, too few medical oncologists admit to patients that they have little or nothing to offer.

Radiation oncologists face similar, unfair criticism. I can't tell you how many times I have heard colleagues complain that "the indication for radiation is the presence of a consult." My own experience with this group of practitioners has been very positive, and I have watched them appropriately decline to treat a number of patients who have very advanced or resistant tumors.

Surgeons are not exempt from the same concern. You and I know surgeons willing to undertake procedures that have no realistic expectation of success or who put patients at unacceptable operative risk. There are clearly defined and objective limits for oncology care provided by medical, radiation, and surgical oncologists, and we all need to follow these guidelines in the best interests of our patients.

With that in mind, patients have to make difficult decisions following consultations with objective and informative oncology specialists. In making our final management recommendations as to which modality(ies) be employed or against further treatment, it is critical that we focus on the quality of our patients' remaining days, not merely the number of them.

I am reminded of the story (sanitized for publication) of the man who went to his family doctor for a routine visit. After a complete examination, the physician met with him in the consultation room. Visibly shaken, he told his patient, "I'm sorry to have to tell you that you have widespread metastatic cancer." The man responded, "That's terrible. How long do you think I have to live?" The physician advised him, sadly, "About 6 months." The patient asked, "What do you suggest I do?" The doctor recommended that he "marry an ugly, irritable woman and move to the tundra of northern Alaska." Obviously puzzled, the patient asked the doctor how such a union would help prolong his life. The response, also the punch line, provided the message, "You'll still live only 6 months, but it will feel like a lifetime."

Patients dying of malignancy do not have much 'lifetime' left. They need to take advantage of all the time available, enjoy good quality of life, and die with dignity. It is important that their terminal period doesn't "feel like a lifetime." Our advice has to facilitate this best possible scenario. Sometimes, the right answer is a bottle of scotch and a fishing pole.