By Xu Kecheng
It was 18th January again, a day that weighs heavily on me. The same day 11 years ago, I was diagnosed with liver cancer and received hepatectomy 8 days later. After regained my consciousness from anaesthesia, I insisted on taking a look on the resected liver lobe, which was the whole left lobe. A yellowish white circular nodule that measured 3cm, close to my right lobe, was found. The chief surgeon, Prof Hu Yize, reassured me that this was the only nodule found, no metastasis.
Prof Hu was an old friend to me. I knew he may not be totally honest with me since experienced doctor understand the importance of being “euphemistic” to patients. I told him that I had to know the pathology result. He hesitated for a second and told me: Cholangiocarcinoma.
I was appalled by the result. Being a gastroenterologist for decades, I knew exactly what that means. There are 2 types of primary liver cancer: hepatomaand cholangiocarinoma, each originated from different type of cells.Compared with Hepatoma, Cholangiocarcinoma, less common and more malignant, develops lymph nodes invasion and distant metastases at very early stage, which indicates worse prognosis.
Days after surgery, I could sit up on the bed. I started surfing internet and found an article publish on World Surgery Magazine in 2005 by a doctor from Taiwan. The article reviewed 81 peripheral cholangiocarcinomapatients who received hepatectomy from 1977 to 1997, of which only 11 patients survived more than 5 years, accounted for merely 13.6%. The author was pessimistic and concludedthat surgery doesn’t make much difference.
I turned to The Guidelineand found it stated that cholangiocarcinoma patients can receive “adjuvant chemotherapy” and benefit from this treatment with medium survival time 1 to 3 months longer than the control group without chemotherapy.
This conclusion raised a question to me “what is the purpose of cancer treatment?” The only purpose for me is to survive for a long time. If it means spending the extra few months with nauseating, vomiting, hair-losing and all other painstaking side effects, I don’t think I want it. Even if I managed to hang on for a few months, I couldn’t do anything that I really want to do. After much deliberation, I told my doctor that I will decide the fate for myself with the treatment chosen by myself.
It takes much to learn. For the past few years, quite many cholangiocarcinoma patients came to our hospital. Some of them have read my book Follow Me to Fight Against Cancerand most of them were found to have metastases shortly after surgery, or1to 2 years or several years after surgery. They had multiple metastases that diffused all over the liver. Some even had metastases to lung, bone and abdominal cavity. Those patients shared one thing in common: they all had chemotherapy and the tumor metastasize as they undergo chemotherapy.
Their adversity compounded my question: for cholangiocarcinoma patients, does chemotherapy do more good than harm or the other way around?
Well, those admitted to our hospital don’t represent the whole picture. There are patients who had no recurrence or didn’t go through chemotherapy that were not admitted to our hospital, like myself. To answer my question, I regularly search for papers worldwide and I should have read more than 1000 papers published in western countries with SCI label, hoping to find the CURE for other patients and for myself as well.
It had been very disappointing. A large meta-analysis reported that Adjuvant chemotherapy or radiotherapy did not appear to be beneficial. (JAMA Surg 2014;149(6):565-74). This analysis included 57 researches and involved 4756 cholangiocarcinomapatients from 49-67 years old. 57% of them are male patients and 69% of them are having solitary tumor, the medium tumor size of 86% patients was 4.5-8.0cm. 82% of the patients received hepatectomy. Medium survival time is about 28 months and 5-year-survial-rate is 5%-56% with a medium of 30%.
Then what about the much-concerned molecular targeted therapy? In the phase III of a large randomized controlled trial published on Lancet Oncology, the tumor responsive rate increased from 14% to 31% for 180 cholangiocarcinoma patients who were on Gemcitabine combined with EGFR receptor blocking agent Gefitinib. The author argued that the efficacy was inspiring but limited.
Papers published in 2016 don’t show much promising prospects either. An article by British scholar reviewed more than 60 papers and concluded that very few cholangiocarcinoma patients can undergo surgical resection and the efficacy of adjuvant chemotherapy and radiotherapy after surgery is very limited.
This is the dilemma faced by doctors and patients: inspiring treatments don’t prolong patient’s survival time inspiringly. Cancer is characterized by heterogeneity - different cancers stem from different cells; even the same type of cancer that stem from the same type of cells produce different type of cancerous cells. The reason chemotherapy doesn’t work that well for Cholangiocarcinoma is that those cancerous cells are not responsive to the chemotherapy since they were “born” that way.
I pointed out, in another article titled “what we can do when chemotherapy fails”, that chemotherapy induces genetic mutation of cancerous cells, leading them astray, which makes those cells not only immune to chemo drugs, but also more malignant. This answers the question “why cancer metastasize as patients undergo chemotherapy”.
When considering chemotherapy for patients, doctors should ask more questions with focus on the stability of the wholebody, not only the tumor itself. Such as the following questions: Will this treatmentbe able to prolong patients’ life for years, not only few days, months? Or will it kill the patients faster.
Whenever I exchange my idea with leading authorities in this field, their words imply scepticism as well:
Academician Wang Zhenyi, a haematological tumour expert, first introduced Leukemiainducingdifferentiationtherapy in the world. He said: “when I attend academic conference, I found most researchers publishing quality papers about “gene” and “target”. But I doubt if those researches are useful for patients”. He quoted, from On Protract War- save yourself while eliminate the enemy, that how you can eliminate the cancerous cells if you don’t boost the immune system, not to mention harm it with chemotherapy?
In an e-mail from Academician TangZhaoyou, he mentioned “When I visit patients in the ward, I ask every colon cancer patient with liver metastases if they had any other treatments after surgery and they all told me that they had all 6 cycles of chemotherapy. I told my fellow doctor that chemotherapy doesn’t work for those patient, not those with liver metastases. Some doctors don’t see eye to eye with me on this and argued that chemotherapy is the standard treatment that was tested by randomized controlled trial… Well, chemotherapy was indeed tested by trials, but I believe only practice can be the criterionfor truth, which is the therapeutic effect, not trials.
In his book China’s Way of Fighting Against Cancer,Academician Tang Zhaoyou quoted, from The Art of War by Sun Wu, that “make yourself invincible and wait for opportunity to fight back”, which is to say, we should first consider how to make our body defeat cancerous cells. To boost your immune system and save your strength to defeat the enemy.
Confronted with these situation, academician Tang further noted: you must learn how to question before you can do better than your predecessor, it seems there had been very few questions.
I think I am the lucky one, for that I have been surviving for 11 years, thanks to my “questions”.