It seems our society lives in dread of cancer, one word that is the purgatory of the modern western world. How often does a patient reply, when you tell them the positive results of an investigation, “Thank heavens it isn’t cancer” even though the actual diagnosis may be more life threatening than many neoplasia. The almost biblical belief system behind the word cancer comes with a corollary that poses a major problem to effective rational health care, namely the “must get it out” association. That medical school surgical dictum “When in doubt, cut it out” may have been superseded by more politically correct phrases, but the thought remains ensconced in our own and our patients’ minds when faced with a diagnosis of a solid neoplasia.

But why is this so? Why do we believe that a diagnosis based on visualisation of some cells down a microscope has a 100% positive predictive value, especially when the patient has absolutely no symptoms or clinical signs to support the diagnosis? Have you ever tried to explain the gap between a histological and a clinical diagnosis to a patient?
Not easy, yet we know from the prostate screening studies that a histological diagnosis of prostatic carcinoma is poorly predictive of subsequent death from that cancer. Try the melanoma studies demonstrating a significant interoperator variability in histology results. What about the phenomenon of diagnostic drift, especially the recent study showing that, in current day reviewing of skin biopsy slides diagnosed as normal in the 1990s, a significant number were found to be low grade superficial spreading melanoma. Little wonder we are removing more melanomas than ever before.

What we really need is a change of thinking, more focused on a “cancer” diagnosis based on metastatic disease potential (ignoring the problems caused by primary tumour enlargement, but remember that this includes plenty of non malignant growths). This requires a different diagnostic method and is the likely way things will move in cancer diagnosis. Consider if we had a test for prostate cancer that had a better predictive ability for the development of metastatic or local spread disease. Same for breast cancers, especially the very problematical DCIS.

Sentinel node biopsy seems to have potential, at least in terms of identifying if metastasis has already occurred, but greater potential is likely to lie in biochemical indicators of metastatic activity and potential, such as have already been found in inflammatory breast cancer. It’s unlikely imaging as we know it will be a suitable answer, but perhaps, in conjunction with metastatic markers, we may be able in the future to reassure patients that their cancer is better lived with, rather than without.

Our challenge will be to shift this cancer belief system and the associated concepts of appropriate therapy.

A BMJ article on aortic aneurysms jogged my memory of a conference workshop where a well known local researcher described a square shaped age mortality curve that is developing as people live longer and are more likely to be taken by the grim reaper of unavoidable disease. Square shape rather than a regular drop off of say 2% of the population per year of aging as happened in past decades and centuries. One where everyone gets to live to say 90 and then drop off like flies, dying not of conditions like infection, premature CVD and cancers, but being claimed by degenerative diseases especially neurological and complex interactions of multiple co-morbidities and polypharmacy.

Even the way accidents claim lives is changing especially in affluent nations. Improved motor vehicle, industrial and sports safety have greatly reduced individuals' chance of injury and death, even for the adrenalin junkies who persist in trying to leap from high buildings, swim with sharks, kayak down raging torrents and climbing into backyard balloons. In the 50s only Superman indulged in these sorts of activities, except the last. Nowadays every mother's son (and daughter) seems to be into some form of extreme sport and despite this, there has not been a large growth industry in accident fatalities in the first world. Maybe it’s the risk adverse behaviour indoctrinated into modern generations by baby boomer one and two child parental anxiety.

Actually the baby boomers aren't only a problem as parents. They are failing to follow their parents example of growing old gracefully. According to accident insurance data they're still out there falling off their bikes, skis, motorcycles and even taking up new sports when they should be sitting back sipping their tea and eating their scones. Is it the butter in scones, the poison left after you have taken everything good out of the milk. But have you ever made scones with olive oil? * 

This square curve, besides being an oxymoron, now poses family physicians with a need to consider a new realm of social and ethical issues when it comes to interventions in the multiply co-morbid elderly. Is it worthwhile replacing this 80 year old's arthritic knee when he has CHF, prostatic cancer and moderate renal failure? How realistic is the patient's expectations?  How realistic is societies? Does it equate with those of his cultural group? What if he was a fit health 90, no pills, no diseases (other than the ubiquitous NSAID) but with a 50% chance of dying in the next 2 years?   

Fortunately the curve still had a round corner to it, but how long before an Orwellian system develops a polypill with a timed euthanasia component?

Anyway I'm taking up kite surfing when the weather warms up and it’s too hot to have tea and scones. It is safe they tell me.

*Scone: a peculiarly English cake, often served with cream of some type.    

Coincidences are the food of blogs.

Last weekend our media was full of the return to the ring of NZ's favourite heavy weight boxer David Tua, complete with the pre fight hype, posturing and verbal abuse so typical of the sport. This was while I was researching the guidelines for traumatic brain injury diagnosis and management for a medicolegal case. How could I be comfortable watching the glorification of a brawling boxer who would deliberately, in a few hours time traumatise the brain of an opponent for significant personal gain, while before me lay the clinical records of an accidental head injury patient, to be analysed for the possible outcome of shaming and blaming a doctor who I am sure at no point had intent to maim or wound.

My discomfort was aggravated when the fight finished in the 2nd round with the loser clearly suffering significant brain trauma. A GCS of 14, judging from the short clip of the defender's corner after the bout ended. I bet someone did a CT of his head, probably funded by the public accident insurance. I wonder if anything was found?

Drawing parallel between two vastly different circumstances might seem unfair and some friends have railed against me for complaining about the oxymoron of labeling boxing as a sport and then supporting its banning. They point out that air sports, including some I have personally engaged in, have a far higher death rate. But a glider pilot does not fulfill a personal need by causing grievous body harm to a fellow human. Another pointed out that this was only the top echelon of the sport, for amateurs had head protection which presumably allow them to punch the opponent even harder in the head. Good for releasing all that aggression. Somewhat reassuring, until I saw another TV clip of bar patrons fighting over the outcome of the Tua fight! Presumably they were professionals.

Straining my single brain cell, I wondered why the UK had banned fox hunting but professional boxing continues...do humans care more for foxes than fellow humans? Do we need a new species. Homo Sulgerius.

Now this could get silly and the anti-boxing thing has a certain element of being the domain of greenie, libertarian, tree huggers, but didn't the World Medical Association and the British Medical Association call for the sport to be banned, and the national medical associations of Australia, Bangladesh, Canada, Denmark, Finland, Ghana, Ireland, New Zealand, Nigeria, Norway and South Africa have all lent support to this.

Why do nations permit and glorify such deliberate injury (with long term sequelae) to a fellow human for personal gain, both financial and emotional but forbid so things like smoking in public places because there is a small risk of unintentionally causing harm to other humans. Is it just that boxers have effectively given consent to being harmed when they take up the sport? Is that informed consent? Is it before or after the brain injury sets in?