The heat is on again in the world of cancer treatment, both literally and figuratively.
More and more doctors are now using an extremely aggressive procedure to treat certain colorectal and ovarian cancers called Hipec, in which patients first undergo surgery to remove any visible cancer, then have heated chemotherapy pumped into the abdominal cavity for 90 minutes to kill any remaining cells.
Although it has given some patients hope, there is almost no evidence that the treatment is more effective than traditional chemotherapy — besides one small trial in the Netherlands over a decade ago that did show a benefit, but in which 8 percent of the participants died from the procedure itself.
We shouldn't be surprised by the sudden emergence of this therapy. Heated chemotherapy is the latest in a long list of very toxic treatments used by well-meaning cancer doctors who have confused doing more for patients with doing what is best for them.
History tells us that this "more is better" dictum is rarely true.
Aggressive cancer therapy started in the late 19th century with the radical mastectomy, which involved the removal of the breast, along with the chest muscle below it and nearby lymph nodes, and was championed by William S. Halsted, a surgeon at Johns Hopkins.
In the following decades, Dr. Halsted's methods became more and more popular, particularly after World War II, when surgeons who had performed heroic operations on European battlefields returned to America optimistic about what could be achieved in cancer surgery. In an attempt to eradicate all potentially dangerous cells without the assistance of chemotherapy — which was not yet in wide use — surgeons began removing even parts of the sternum and rib cage of certain breast cancer patients in something called a super-radical mastectomy.
If the cancer had spread into the arms, surgeons at times removed entire shoulders (forequarter amputations). If the cancer was in the legs, part of the pelvis was removed with the leg (hindquarter amputations). The most aggressive operation of all was probably the pelvic exenteration, devised by the New York gynecologist Alexander Brunschwig. For cancers that had spread throughout a woman's pelvis, he removed not only her gynecological organs but also her bladder and rectum.
The goal of these operations was straightforward: to remove as many cancer cells as possible, which would theoretically prolong the survival of patients and possibly even cure them. The problem was that none of these procedures had been formally tested in controlled clinical trials. By the 1960s, it had become clear that they were of little or no benefit, while causing dying cancer patients disfigurement and suffering.
Why such enthusiasm for aggressive surgery? The explanation can be gleaned from the language surgeons used to justify their operations. Military metaphors were ubiquitous. In 1946, Cushman Haagensen warned his colleagues against "surgical cowardice" in the face of the "formidable enemy" that was cancer. Jerome A. Urban, the father of the super-radical mastectomy, was fond of saying "lesser surgery is done by lesser surgeons."
It was not only surgeons who made these assumptions. In the late 1980s, oncologists began treating metastatic breast cancer patients with a highly toxic and expensive regimen of so-called very-high-dose chemotherapy, followed by bone marrow transplants. Once again, early data proved misleading. Women who received this treatment turned out to live no longer than those getting standard chemotherapy, and many died from either the high doses or the side effects of the transplants.
Cancer patients and their families, desperate for anything that might work after exhausting all other treatment options, are also part of the problem. But the history of cancer treatment provides a crucial cautionary tale for both those seeking out and those providing heated chemotherapy today. Doing more for cancer patients has often served a cultural as opposed to a scientific purpose, reflecting more the desire to defeat the cancer enemy than to take care of sick patients. Hospitals should offer heated chemotherapy — and insurance companies should pay for it — only after controlled trials have proved its effectiveness.
In the meantime, we should remember not to conflate our efforts with our achievements.
