It is my wish that we could collaborate and determine standard-of-care algorithms to determine exactly when all curative therapies should end.— Guy Faguet, MD
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The history of medicine once was featured in medical school curricula. That is becoming less common due to time restriction and the increased prevalence of more technical topics. However, the importance of the history of medicine cannot be overstated: It shapes every aspect of our cultural, political, and philosophical commitments. The ASCO Post recently spoke with Guy Faguet, MD, a retired hematologist/oncologist who is also a noted medical historian. Dr. Faguet discussed oncology history as well as his views on the current state of certain aspects of cancer care.
Please tell the readers a little bit about yourself.
I was born in Italy and grew up in France and Colombia, where I obtained my medical degree at the Universidad Javeriana Medical School. My postgraduate medical education was mainly at The University of Texas Medical Branch in Galveston and at The Ohio State University in Columbus. My 30-year–plus academic career evolved at the Medical College of Georgia and the affiliated VA Medical Center in Augusta, Georgia, lasting through my retirement. I was engaged in patient care, teaching, and clinical and bench research. I am the author of 139 peer-reviewed publications and six books on cancer therapy and public policy.
History of Cancer Enthusiast
You’ve written extensively about the history of cancer. What spurred your interest in this subject?
I am a firm believer in learning from the past, digging for clues in the history of cancer that might provide insight into our current oncologic treatments. As a society, we have a tendency to discard the old in favor of the brand new, which doesn’t always produce the best options for treating our patients with cancer. Understanding history gives one an underpinning for our advancing knowledge base and, even though many of the earliest physicians didn’t possess the tools to fully understand cancer, their critical thinking process is something we can still learn from. Moreover, studying disease in antiquity is intellectually stimulating.
The earliest written record describing human cancer appeared in ancient Egyptian manuscripts, written, of course, on papyrus and discovered in the 19th century. They describe surgical, pharmacologic, and magical cancer treatments. Malignant growths have been detected in million-year-old dinosaur bones. The earliest cancerous growths in humans were found in Egyptian and Peruvian mummies, dating back to about 1500 BC, but the oldest scientifically documented case of disseminated cancer was discovered in a middle-aged Scythian king from Southern Siberia who lived about 2,700 years ago. The microscopic and proteomic techniques confirmed skeletal lesions of prostatic origin.
Hippocrates, famous for his oath, wrote extensively about diseases that produce masses he called onkos and coined the name karkinomas for ulcerated growths he considered incurable. He wrote, “It is best not to apply any treatment in cases of karkinomas, for if treated patients die quickly but if not treated, they hold out for a long time.” The Roman Claudius Galenus (129–210 AD), classified tumors into “tumors above nature,” such as normal physiologic processes of enlarging breasts or uteri, and “tumors beyond nature,” which included abscesses as well as Hippocrates’ onkos and karkinomas.
Let’s not forget the many contributions of the Middle Ages and of the Renaissance that took us to the National Cancer Act passed by the U.S. Congress in 1937 and to the first chemotherapy drug discovered a few years later, ironically derived from mustard gas—a chemical warfare agent. So, from antiquity to the present, the history of cancer is both fascinating and instructive.
Epidemiology of Disease
You’ve also written about the history of epidemiology and the value of connecting the dots between the causal factors of disease. Please briefly discuss this issue.
Today, we have a body of knowledge about the clinical health issues related to the workplace. The father of that line of inquiry was a doctor named -Bernardino -Ramazzini, who was born in -Carpi, Italy, in 1633. When he was a medical student at Parma University, he became interested in diseases suffered by workers and was the first to focus on worker’s health problems in a systematic way. He routinely toured workplaces and observed the environment and activities, discussing the workers’ illnesses with them. After dedicating most of his life to workers’ health issues, he published a comprehensive book detailing his observations, called Diseases of Workers, which described 52 occupational illnesses. Interestingly, Ramazzini is the first researcher to point out the low incidence of cervical cancer in nuns compared to married women, connecting the latter to sexual activity; a link proved by later evidence.
Then, in 1761 John Hill, MD, of London, first suggested the relation between tobacco products and cancer. In his pamphlet Cautions Against the Immoderate Use of Snuff, he reported a link between excessive indulgence in tobacco snuff and cancer. At about the same time, Percivall Pott called attention to scrotum cancer in chimney sweeps.
We owe a huge dept of gratitude to the giants who came before us and had the genius and foresight to think out of the box and investigate possible causes of cancer development that at times were met with scorn and skepticism by the mainstream establishment, as is often the case.
The Era of Cytotoxic Agents
Please share your concerns about the frustrating lack of progress over the past decades with cytotoxic therapies.
I expressed my opinion on this subject in my books, The War on Cancer and The Conquest of -Cancer. To begin with, cancer is often called neoplasm, a term coined many decades ago suggesting that cancer is a new growth and not really part of the human body. Yet, it is well documented that cancer arises from a mutation in normal cells and therefore is part of the self. Hence, drugs designed to kill cancer cells —which I call the cell-kill paradigm—also affect normal cells to various degrees and cause serious side effect in cancer patients.
That said, many of these chemotherapeutic agents induce remissions and even cures in some cancers such as large cell lymphomas, acute lymphoblastic leukemia, and others. However, I believe the era of cytotoxic agents should come to an end. As a community, we need to move ahead with concerted efforts to find and develop new early detection methods across all cancers so early surgical interventions and other yet to discover approaches have a chance at cure before metastases occur. I believe that if we can abandon the dogma of the cell-kill approach as the basis of advanced cancer management and focus our efforts on early detection, we can defeat cancer.
Cancer Pain
Cancer pain is another area that you’ve examined closely. Can you share your thoughts on our shortage of parenteral opioids and the growing reluctance by many physicians to prescribe opioids for cancer pain?
The oncology community has worked very hard to ensure that patients with cancer have proper pain control; however, the unintended consequences of the opioid crisis have hurt our previous efforts, and now we are seeing an increase in undertreated cancer pain. The National Cancer Institute has published studies showing that opioid addiction among patients with cancer is statistically insignificant, occurring in rare cases when a patient has a history of addiction. That’s because patients with cancer take opioids to relieve pain, whereas addicted individuals take opioids for their psychological effects.
Personally, in my 30 years of oncology practice, not a single patient of mine became addicted to opioids I prescribed. In fact, on many occasions I had to persuade patients to take opioids as prescribed rather than skip doses fearing addiction. In my view, addiction is not a disease, as is the current consensus and, quite frankly, exacerbates some physicians’ reluctance to prescribe sufficient pain medication for fear of legal pursuit. Addiction is a behavior problem and should be dealt with accordingly. I discuss this tough issue at length in my book Pain Control and Drug Policy.
End-of-Life Care
Please share some closing thoughts on cancer care moving forward.
I’ve published extensively on end-of-life care for patients with advanced cancer, especially when the initial treatment has failed and further chemotherapy is unlikely to succeed. Although there have been great gains in palliative care, studies and surveys conclude that most patients with cancer during end-of-life care receive unnecessary chemotherapy up until the last week or so of life with little attention to palliative care. This is not good care and adds undue discomfort during the patient’s most vulnerable period, facing his or her mortality.
In my view, achieving quality end-of-life care and promoting death with dignity will require to view the person rather than the disease as the unit of care and develop a pragmatic definition of end of life. Such a strategy should facilitate selecting an optimal time to transition from disease-targeted treatment to palliative care.
DISCLOSURE: Dr. Faguet reported no conflicts of interest.
