How to live with cancer
China News Weekly reporter/Li Mingzi
Issued in the 994th issue of China News Weekly on May 5, 2021
In 2014, Li Qing's father found a shadow on the left lung during a physical examination. After further examination, he was diagnosed as "early non-small cell lung adenocarcinoma."
The attending doctor said, “Surgery is sufficient for early lung cancer, and there is nothing to worry about.” So he underwent radical surgery for lung cancer.
Unfortunately, two years later, the lung cancer recurred.
Since there was no genetic mutation after the test, it did not meet the conditions for using targeted drugs, so I had to receive chemotherapy first: use cisplatin combined with pemetrexed and bevacizumab, go to Guangzhou for chemotherapy every three weeks, and treatment for 6 cycles .
During this period, Li Qing and her mother started to check the Chinese and English materials by themselves, plus the experience of the patient group for consultation and medical treatment, and brushed the popular science posts of the Chinese Academy of Medical Sciences Cancer Hospital and Peking University Cancer Hospital every day to learn about the latest drugs and therapies.
At that time, I heard many people talk about their experience of going to the United States to see a doctor, and my father’s doctor friends also recommended several American hospitals that specialize in oncology.
Therefore, Li Qing's family finally chose to receive treatment at the famous MD Anderson Cancer Center in Houston, USA.
In Anderson, the results of genetic testing are still all negative, which means that targeted drugs are still not available.
The chemotherapy regimen given by the doctor is consistent with that in China, "it is strongly not recommended to change the drug", but it is only considered that if drug resistance appears in the next step or the condition deteriorates, then find a new drug or perform immunotherapy.
Cancer becomes a chronic disease
Back in China, Li Qing's father still regularly went to Guangzhou for chemotherapy. He was hospitalized for two or three days each time. After half a year, his condition further developed and he received another course of cisplatin.
In order to control tumor progression, the chemotherapy drug was replaced with paclitaxel, and the immune drug K drug was used.
Drug K is a type of PD-1 inhibitor for tumor immunotherapy. It is simplified from the Chinese name Kerida. It was only approved in China for the first-line treatment of lung cancer in March 2019.
Existing clinical trials have shown that after K drug combined with chemotherapy, the tumor shrinkage ratio is more than twice that of chemotherapy alone, and it reduces the risk of death by 51%.
The results of a highly anticipated large-scale study showed that the median survival time of drug K combined with chemotherapy drugs in the treatment of non-small cell lung cancer reached 22 months, which was twice the median survival time of 10.7 months in the chemotherapy alone group.
This means that advanced patients who have not yet developed a gene mutation have time to squeeze through the "narrow door", and successfully survive until the gene mutation is detected, and thus enter the stage of targeted drug therapy. They say they have the opportunity to be longer and more effective. Live quality.
Li Qing's father is one of the beneficiaries of this therapy.
By the end of 2019, he had used two rounds of first-line chemotherapy drugs, but the effect was getting worse and worse.
In March 2020, his condition deteriorated again and no suitable chemotherapeutics were available. The doctor advised him to do another genetic test. If the test result shows a genetic mutation, he may receive targeted therapy, which will bring the last hope to prolong his life.
"He was lucky, and finally a'diamond mutation' appeared!" Li Qing explained, "If a lung cancer patient has a positive mutation of'anaplastic lymphoma kinase (ALK)', it means that the treatment of targeted drugs is particularly sensitive and the treatment effect Good. But the probability of ALK mutation in non-small cell lung adenocarcinoma is very low, only 3% to 8%, so it is also called the'diamond mutation'."
In the impression of Li Qing’s father’s generation, cancer is a terminal illness, not to mention the terminal stage of cancer, which almost declares the end of life.
However, the current situation is actually completely different.
The current targeted drugs can be taken for two years under ideal conditions. Even if drug resistance appears in the future, there are other second and third generation targeted drugs to replace. In this way, lung cancer can be controlled like other chronic diseases of the elderly and patients can maintain Better quality of life, get rid of the pain caused by the original monthly chemotherapy time limit and side effects.
What brings hope to cancer patients is several innovations in anti-tumor drugs.
In 1997, the world’s first targeted drug, rituximab (injection), was launched in the United States for the treatment of non-Hodgkin’s lymphoma, which combats cancer cells while reducing damage to normal cells, unlike the original Radiotherapy and chemotherapy, "kill one thousand enemies, damage oneself 800", thus opening the era of precision cancer treatment.
By 2001, the small-molecule targeted drug Gleevec was born, which increased the five-year survival rate of patients with chronic myelogenous leukemia from 30% to 90%. Patients can control tumor development by taking medicine at home, and individual cancers become like hypertension. , "Chronic diseases" like diabetes.
In 2003, targeted drugs were launched in China.
Nearly 50% of patients with advanced lung cancer can prolong their survival to more than 3 years through targeted therapy.
Researchers from the National Cancer Center, the Chinese Academy of Medical Sciences and other institutions analyzed the 5-year relative survival rates of 26 cancers from 2003 to 2015 in 17 cancer registries in China. This number rose from 30.9% to 40.5 from 2012 to 2015. %, an increase of nearly 10% in ten years.
According to the latest data from the American Cancer Society, as of January 1, 2019, the number of patients living with cancer in the United States has exceeded 16.9 million. Without accounting for technological development and medical changes, this number is expected to be January 1, 2030 It will also reach 22.1 million.
“There are many treatment methods such as targeted drugs, precision treatment technology and immunotherapy. There are many patients with locally advanced lung cancer who live for more than 20 years after diagnosis.” Chairman of the Lung Cancer Medical Education Committee of the Chinese Medical Education Association , Zhi Xiuyi, director of the Lung Cancer Diagnosis and Treatment Center of Capital Medical University, said, "We can actually treat tumors more calmly."
"Nowadays, many patients can live with cancer. What we are more concerned about is how to make patients with advanced cancer survive longer and live better." Zhi Xiuyi has been engaged in cancer clinical work for nearly 40 years. He found , The patient is "fear of cancer" because he does not understand the condition, not just afraid of the disease itself, but also afraid of the pain suffered during cancer treatment, and the negative impact of side effects on life and work. They do not want to lose their work and life. Fun, unwilling to live without dignity.
Update concept
After graduating from Beijing Second Medical College (now Capital Medical University) in 1983, Zhi Xiuyi was assigned to work in Beijing Tuberculosis Lung Cancer Hospital (now Beijing Chest Hospital Affiliated to Capital Medical University).
At that time, doctors could only diagnose lung lesions through chest X-rays, not even CT.
At that time, once lung cancer patients were diagnosed, more than 80 to 90% were advanced or locally advanced.
Statistics show that in the 1980s and 1990s, the median survival time of advanced lung cancer in China was generally no more than 10 months.
In the past two to three decades, the level of diagnosis and treatment of cancer in clinical medicine has been greatly improved.
High-precision CT examinations allow more cancer patients to receive early diagnosis and receive minimally invasive surgery and postoperative adjuvant treatment at an early stage.
"Take early lung cancer as an example. After surgical removal, the five-year survival rate can reach more than 90%, and the 10-year survival rate is also very high. We call it clinical cure." Zhi Xiuyi said.
"At that time, going abroad to see a doctor was to spend money to buy peace of mind." Li Qing told China News Weekly that the norms of lung cancer treatment are internationally applicable, not that in the United States, there is a magical medicine that can cure all diseases.
In the United States, it cost nearly 100,000 yuan for a two-day checkup. Although there was no substantial gain, I was relieved a lot about the domestic chemotherapy regimen because Anderson’s diagnosis and treatment plan was discussed by a team of doctors instead of relying on one. The attending doctor draws a conclusion, so it is rarely misdiagnosed.
The team discussion that Li Qing said is called the "multidisciplinary joint diagnosis and treatment model" in medicine, or MDT in English for short, and has been developed internationally for more than 60 years.
In the 1940s, the Anderson Cancer Center organized a number of medical doctors together in the form of a tumor case seminar to review the problems that occurred in the diagnosis and treatment process and discuss solutions. At that time, the main purpose of the seminar was medical education, not attention. patient.
In 2009, a cohort study in the United States counted 269 patients diagnosed with urinary system cancer. After these patients received multidisciplinary consultations, 23% of bladder cancer cases and 17% of kidney cancer cases were diagnosed. Variety.
Another British study showed that the three-year survival rate of 134 patients receiving multidisciplinary diagnosis and treatment was 66%, which was significantly higher than the three-year survival rate of 176 patients in the control group of 58%.
Multidisciplinary consultation can effectively avoid misdiagnosis and prevent doctors of different specialties from biasing treatment options.
"Our understanding of cancer is advancing. Many tumors are not just local problems, but systemic diseases. The pathogenic factors include family genetics, environmental or occupational pathogenic factors, and even personal lifestyles. Patients who live with cancer for a long time The treatment does not depend solely on a certain discipline, and ultimately does not necessarily die due to cancer. Taking lung cancer as an example, the early treatment is not limited to thoracic surgery, and the advanced stage is not only in the oncology department. The diagnosis and treatment of lung cancer includes multiple departments. Emphasize comprehensive treatment." Zhi Xiuyi said.
Recognizing the complexity of cancer, after Zhi Xiuyi returned to China from the Miami University Cancer Center, he established the nation's first medical university lung cancer diagnosis and treatment center in Xuanwu Hospital of Capital Medical University in April 2003.
He said, "The diagnosis and treatment center focuses on lung cancer patients, and arranges comprehensive treatment in different disciplines according to the tumor pathological type and clinical stage."
According to Zhi Xiuyi's understanding, MDT is now basically available in the top three hospitals in all provincial capitals in China. Some focus on diagnosis, treatment and research, and some focus on popular science. However, only 50% of MDT methods are fully adopted. Therefore, Need to be further promoted.
With the aging process of the Chinese population and the impact of environmental carcinogenic factors, the high incidence of cancer is inevitable. Instead of being tortured between the despair and hope brought by various therapies when the tumor is advanced, it is better to pay attention to the primary and secondary prevention of tumors. .
Among them, the former refers to the prevention of the cause of the disease, the purpose is to identify and eliminate the risk factors of cancer, and prevent it before it happens.
The latter refers to early detection, early diagnosis, and early treatment of malignant tumors, and its purpose is to increase the cure rate and reduce the mortality and disability rate.
One of Zhi Xiuyi's main work in recent years is to call for cancer prevention and early diagnosis and treatment.
"What ordinary people can do is to screen and diagnose early, so as to achieve early treatment and early recovery. Only by doing this can they face cancer calmly." Zhi Xiuyi said, the "Healthy China 2030" Planning Outline" proposed One of the means to achieve the goal of "improving the overall 5-year survival rate of cancer by 15%" is to "carry out early diagnosis and treatment of key cancers in high-incidence areas."
How to live with cancer
Recalling the experience of breast cancer surgery in a domestic hospital at the beginning of 2016, Cao Xue could still feel cold all over her body involuntarily. “The dozen or so hours were too long for me, and the feeling of skin-cutting was pain and cold.” Cao Xue recalled that she was the first to be pushed into the operating room for biopsy at around 7 o'clock in the morning of the operation, and then she was pushed back to the ward to wait. Waiting in the corridor of the operating room, staring at the ceiling, shivering with cold.
Cao Xue woke up with pain after the operation. At that time, the right breast had been inserted into the stent to stretch the skin for subsequent reconstruction.
She was sore and sweaty almost every night, and sometimes she had to change three sets of pajamas, and she had the impression that the doctor had not given her analgesic treatment.
At that time, Cao Xue hadn't passed her fortieth birthday.
She was hospitalized for a month after the operation. The painful experience of wound leakage, bleeding, and pain made her sober, and she began to search the rankings of hospitals in various places. It happened that the family business had a business in the United States, so she contacted the Dana-Farber Cancer Institute in Boston. Flew to Boston on the night of New Year's Eve.
Cao Xue went to the outpatient clinic at Dana-Farber, received radiotherapy after right breast surgery, and then was hospitalized at Brigham and Women’s Hospital for left breast resection. The two adjacent hospitals are connected by a bridge, both of which are Harvard University Medical School. The affiliated hospital, in 1996, jointly established the Dana-Farber/Brigan Cancer Center.
Before the operation, the doctor told Cao Xue that one day in the hospital is enough, two days at most, and one week later, she can play baseball and golf. She is only joking as a doctor.
When I woke up after the operation, the doctor and my sister were already guarding both sides of the bed, with pillows under their arms and legs. "Comfortable and warm. I know very well that I don't hurt." Cao Xue never asked the doctor how to give it. She relieved the pain, but she was really discharged from the hospital on the third day after the operation, as the doctor said.
In fact, 80% of cancer pain can be controlled by drugs, and 20% of refractory cancer pain can be controlled within a tolerable range through minimally invasive surgery and drugs.
"We are not bad at all in terms of technology. We can do all the operations that can be done in the United States. We basically have all the medicines in the United States, but the biggest difficulty in pain management is the problem of concept." Department of Pain, Beijing Tsinghua Chang Gung Memorial Hospital Executive Director Lu Guijun lamented that many patients still regard "bearing pain" as the virtue and do not know how to relieve pain, and some doctors also ignore the pain of patients.
According to Lu Guijun's impression, in recent years, oncologists who value pain have gradually increased.
In 2014, a Beijing aunt with advanced cervical cancer approached Lu Guijun. She said frankly, “Of course, the cure is to cure the root, but now that the cancer has metastasized throughout the body, there is no cure for it. Did you go to the pain clinic? But I just came here because I couldn't bear it."
Since Lu Guijun came to work in the Pain Department of Tsinghua Chang Gung Memorial Hospital in 2019, one-fifth of the patients in the daily outpatient clinic have tumor-related pain, most of which come until the terminal stage of cancer, and most of them have developed bone metastases.
Due to the promotion of life education, Lu Guijun always receives a lot of news that "patients cannot bear the pain and commit suicide."
In April 2020, a female patient with advanced liver cancer from Heilongjiang tried to commit suicide by cutting her wrist while seeking medical treatment in Beijing, and was sent to the Pain Department of Chang Gung Memorial Hospital two days later.
In order to meet the treatment needs of patients with cancer pain, the department added a cancer pain clinic in June 2020, and the appointment registration has been scheduled for a week.
"The misunderstanding of analgesics by both doctors and patients is an important reason why chronic cancer pain is not treated." Chen Fan, deputy chief physician of the Department of Breast Oncology, Peking University Cancer Hospital, told China News Weekly, the progress of cancer pain Forming a vicious circle, long-term pain stimulates the pathological remodeling of the nervous system, making people more sensitive to pain, and will only endure more pain. The pain will cause the patient's body immunity to decline and relapse more easily.
"The management of cancer pain requires early control, blocking the vicious circle, and taking enough medicine. Opioids are the core medicine for analgesia." Chen Fan said, according to the supplement of the "Clinical Medication Instructions" of the "Chinese Pharmacopoeia" (2000 edition) It is stipulated that the use of opioids by cancer patients has no capping effect.
Studies have shown that 1/3 of patients who have just been diagnosed with malignant tumors have pain symptoms. For patients with advanced tumors, the incidence of cancer pain is as high as 70% to 80%, and 1/3 of the pain is moderate to severe. pain.
If it is said that with the advent of an aging society, cancer will eventually become a chronic and lifestyle disease, then the accessibility of cancer pain management is an unavoidable problem.
It is not only the management of pain, but with the general trend of cancer becoming a chronic disease, the humanistic care in the interaction between doctors and patients is also crucial to the prognosis of tumors.
"Living with cancer requires long-term treatment. It is necessary to deal with hospitals or doctors for a long time. Good communication is also a kind of treatment." Cao Xue recalled that when Dana-Farber had an interview, the doctor told her after introducing multiple treatment options. Said, "If you are my sister, I would suggest that you undergo a complete breast resection." This made Cao Xue feel understood and respected, and no longer isolated and helpless.
The medical services that Cao Xue enjoys when he seeks a doctor in the United States are based on a relatively balanced distribution of medical resources.
A pain doctor who practiced at multiple points in Beijing United Family Hospital said in an interview that as a hospital that is positioned to serve high-end groups, United Family requires doctors to receive an average of more than one hour for each patient when they visit. But the price also matches it-it costs $15 every 15 minutes.
In the public tertiary hospital to which this doctor belongs, he sees a patient in the outpatient clinic for more than 5 minutes. Without him speaking, the patients in the queue are reluctant.
His outpatient number is also hard to find, and it usually takes a month in advance to get it.
During the three years of chemotherapy, Li Qing's father looked for treatment opportunities nearby in Shenzhen more than once. He once found a place for day chemotherapy in a tertiary hospital, but the hospital just didn't use it.
Li Qing speculated that it may be related to the lower ratio of outpatient reimbursement than hospitalization.
In China, secondary hospitals may not be able to prescribe full chemotherapy drugs, let alone community hospitals.
"The long-term diagnosis and treatment of cancer patients also involves the issue of homogenization of medical treatment. You cannot go to Beijing and Shanghai for all diseases. Medical services in various county hospitals and communities must be mobilized." Zhi Xiuyi said, currently in Shandong and other places. The pilot "county and rural integrated medical and health services", if the county does not understand, then look for the remote medical treatment of Beijing University Hospital.
April 15-21 is the 27th National Cancer Prevention and Control Promotion Week.
The theme of this year's publicity week is "Healthy Chinese Health Home-Caring for Life Science and Preventing Cancer".
The National Health Commission proposed that it is necessary to widely advocate the important role of the family in cancer prevention and fight cancer, publicize the concept of family care, promote family as a unit, care and accompany the family with cancer, and effectively reduce the family burden and social harm caused by cancer. .
"Now with all kinds of new drugs and medical methods, cancer is slowly becoming a chronic disease and a lifestyle disease. Don't be overly afraid of this disease." Zhi Xiuyi is currently organizing the compilation of the "Science Guide for Cancer Patients", hoping Transform professional medical knowledge into vernacular that patients can understand.
"To really allow cancer patients to live longer and better lives, they must take the initiative to control their own disease information, grasp their own disease changes, and benefit from new treatment drugs and treatment methods," said Zhi Xiuyi, Tumor As a chronic disease that accompanies patients for a long time, "family members must be qualified family members, and doctors must be qualified doctors."
(All patients interviewed in the text are pseudonyms)
China News Weekly, Issue 16, 2021
Statement: The publication of the "China News Weekly" manuscript is authorized in writing