While in Denmark under an ASTRO/ESTRO fellowship travel grant, Dr.
Brian Kavanagh spoke with a number of oncologists at the University
of Aarhus about their research and the practice of oncology in
Denmark. In this essay, he skillfully weaves Danish history,
philosophy, customs, and landscape into his interviews with four
eminent Danish physicians.
Under a blue Aarhuvian sky in late September,
the climbing ivy reddens over the yellow brick walls of the
university (Figure 1) and splashes
color on a small pond nearby. Its a good time for thoughtful
reflection in a country whose cultural landscape includes a legacy of
Viking warriors, kindly toymakers, and existential philosophers.
Denmark is a small but exceedingly well-organized country that boasts
an outstanding health care system overall, and within this system,
its oncology sector clearly ranks among the worlds elite. The
Danish achievements in this field are easily found in myriad
scientific studies published in all the major international journals.
But although oncologists in Denmark face many of the same challenges
as their American colleagues, their approach to solving problems can
sometimes assume a distinctly Danish focus.
A Modern Princes Battles
Four hundred years before Shakes-peare shaped his tragic legend of
the angst-ridden avenger who would become the most famous character
in English literature, Saxo Grammaticus had recorded in Latin the
earliest surviving transcript of the traditional oral myth of Amleth
[Hamlet], Prince of Denmark.
In the earlier version, Amleth pretends to be a fool to avoid the
wrath of his uncle, Feng, who had murdered Amleths father.
Amleth eventually retaliates by encouraging Feng and his lords to
become stuporously drunk at a royal celebration, restraining them
with the hanging tapestries knit by his mother, and then setting fire
to the palace.
Cai Grau, MD, PhD, was recently appointed to the faculty of the
Department of Clinical Oncology at Aarhus University Hospital. Tall
and fit, never raising his voice above the tone of polite
conversation, he could play the role of the prince but not the fool.
And a millennium later, the drink that served Amleth well in
retaliation now hangs over Denmark to drown out some of the progress
made by Dr. Grau and others in the fight against cancer. Alcohol and
its insidious partner in oncogenesis, tobacco, remain the scourge of
Disturbing trends of increasing cancer incidence and mortality as a
consequence of increasing tobacco and alcohol consumption in Denmark
have been well documented over the past decade.[1-4] And, at the same
time, Danish researchers have recognized the detrimental effect of
continuing these habits during cancer treatment.
With regard to tobacco use, the Danish governments drug
regulatory policies have been fairly supportive of consumer-initiated
smoking cessation efforts. Potentially helpful nicotine replacement
therapy products, such as the Nicorette/Nicotrol Inhaler, are sold in
Denmark as over-the-counter products, whereas the same items in the
United States are prescription medications.
Nevertheless, it is widely believed that the most important
interventional ingredient in a successful smoking cessation program
is a structured schedule of counseling and follow-up evaluation to
monitor patients behavorial changes. But, at least among
primary care specialists in the United States, there appears to be
very little physician initiation of follow-up evaluations and
counseling in situations such as HMO-based patient care where there
is no clear reward for the physician for this type of effort.
Unfortunately, at Aarhus University Hospital, a state-of-the-art
facility equipped for everything from genetic testing to PET
scanning, Dr. Grau has thus far been unable to generate much funding
support for even a small-scale smoking cessation program for patients
receiving treatment for head and neck cancers.
A few of the nurses and I have recently been working with some
patients after hours in counseling sessions to try to help them stop
using tobacco products, Dr. Grau said. But we really
dont presently have the time and the personnel who specialize
in behavior modification techniques to do it properly.
Why should this be the case, when the governing Social Democrats
readily sponsor such a wide range of health care services?
American Humorist Garrison Keillor has described Denmark as the
Worlds Most Nearly Perfect Nation, where
personal freedom of choice is upheld as a vitally important societal
value. It might, therefore, be tempting to suspect that there is an
ironic ideological bias against trying to influence the behavior of
another individual in this setting, because such action would imply
infringement of individual liberty.
Alas, Dr. Grau offers a more mundane explanation: It really all
becomes a question of money and political expediency. Decisions about
allocating resources toward programs to counsel people about the
dangers of tobacco use are made by elected officials whose primary
goals typically include winning re-election within the next few
years. And programs such as those are unlikely to attract immediate
support because the beneficial effects will not necessarily be
demonstrable before the time of the next election.
Legoland and Mother Earth
The city of Aarhus is located in Central Jutland, the large
midsection of the Danish peninsula that includes Legoland, the most
popular Danish tourist attraction outside Copenhagen. The amusement
park features elaborate miniature replicas of famous buildings and
even whole cities fashioned from many millions of the Lego toy blocks
so popular with children worldwide.
Elsewhere in the region, a few small industrial towns and some
historic port cities along the eastern coast are scattered through
and around richly fertile land where Stone Age burial mounds (Figure
2) can be found in the midst of patchwork manor farms, a
testament to the perennial regeneration of agrarian resources that
has nourished Denmark and her neighbors for thousands of years.
Dr. Marie Overgaard is a senior member of the oncology department at
Aarhus. She has nurtured and cultivated clinical research efforts
there for more than two decades, but she does not appear to have aged
at all during that time. Like many of her colleagues at the
University, Dr. Overgaard maintains a healthy lifestyle and opts for
the quiet efficiency of a bicycle for transit around Aarhus (see Figure
While returning home from work one evening after dark, she was
apprehended by an officer of the law for the high crime of riding
without a working headlight on her bicycle. She had no ID cards with
her, and the policeman became quite skeptical listening to someone
who looked and sounded like a schoolgirl claim to be a faculty
physician at the hospital.
After a phone call, the matter was resolved, but not before the
doctor received a stern lecture about the dangers of poor bike
visibility at night and the importance of being able to prove that
she is who she says she is.
One of Dr. Overgaards more recent publications is a report of a
randomized comparison of observation vs radiotherapy following
mastectomy for node-positive breast cancer. The results, analyzed
after more than a decade of patient observation, revealed a survival
benefit for the adjuvant treatment. In Dr. Overgaards
opinion, the trial represents some of the best features of the Danish
system and some of the most exasperating.
Because there are only a limited number of cancer treatment
centers within Denmark, its relatively easy to start a clinical
study and then recruit large numbers of patients within a short time,
especially when the study is being conducted nationwide. Its
also highly advantageous that we have very good cancer registries
with reliable post-treatment follow-up information, Dr.
But in a different sense, she continued, it is frustrating that
in this breast cancer study so many patients had received mastectomy
for early-stage breast cancer.
Dr. Overgaard noted that it has taken a long time for
breast-conserving surgery to become as frequently utilized here as it
is in the United States. Surgeons and others involved in the care of
breast cancer patients have been a bit slow to let go of some of the
old biases about needing to do mastectomy, even though weve
known for a long time that outcomes can be equivalent for early-stage
breast cancer patients with more limited resection and radiotherapy.
The issue of preventive care again arises, and Dr. Overgaard is quick
to add a qualified defense of the surgeons in that regard. We
have to consider that one reason why weve had many patients
requiring postmastectomy radiotherapy might be that their cancers
werent detected at a size appropriate for lumpectomy because
there hasnt been a strong nationwide policy for routine
At present, the national discussion about breast cancer screening in
the United States has begun to shift from a debate about who should
and should not have screening mammography toward the more complex
matter of when it might be appropriate to conduct genetic screening
to determine breast cancer risk estimates.[9,10]
Although preparations to evaluate genetic screening programs are
underway in Denmark, there is more immediate concern to assure
good access to screening mammography across all socioeconomic strata.
Within the 22 regional health care administrations, there are only
two districts that have formal screening programs that include both
educational materials and scheduled mammography within the health
care system. Dr. Overgaard said that the excuse thats
given in the other places is that women who really want a mammogram
will be able to request one and obtain it, anyway.
But the problem with this approach, she said, is that only
younger women will tend to take advantage of screening programs, and
older women, who probably have the most to gain from screening, are
unlikely to have mammograms routinely. This is because, over the
years, theyve grown to trust the health care system and
dont feel a need to ask for more from it than is already being
given to them.
A Future of Dansk Design
After the overnight transatlantic flight, a sleepy traveler arriving
in the Copenhagen airport awakens to a quiet, clean, mechanized world
of stylized utilitarianism. Tall windows arc around corners opposite
spotless white walls with neatly framed artwork, and escalator steps
pace slowly until they sense the weight of a passenger, when their
cadence quickens to hasten transit up or down. Multicolored neon
lights are bright against the ambient morning gray to beacon
newsstands and coffee shops near the main concourse area.
From here, a transfer to a domestic flight is a straight walk through
another long, white corridor where the only sound is the whisper of
the glass and polished steel doors automatically ushering entry to
the departure gates.
The intellectual epicenter of cancer-related academic endeavors in
Aarhus is found in the person of Jens Overgaard, professor and head
of the Department of Experimental Clinical Oncology (Figure
4). The husband of Marie Overgaard, Prof. Jens Overgaard is a
kinetic visionary who oversees a wide range of laboratory
investigation and also has direct or indirect involvement in almost
all of the clinical trial designs and analyses.
His black Labrador retriever hustles to keep up with the masters
long, loping strides when they go for a walk; fellow scientists must
think fast to remain in step with one of the most active minds and
prolific researchers in the field.
The author of nearly 300 scientific articles and editor of a major
international journal (Radiotherapy & Oncology), Prof. Overgaard
is a future-oriented savant who is also wise enough to appreciate
that progress tomorrow is the result of yesterdays hard work.
His own father initially established the department Prof. Overgaard
now chairs, and the entire Overgaard family respect the history and
culture of the place in which they live.
For example, before entering university studies, the two older sons
of Jens and Marie both spent time at a folkeh (jskole, one of the
folk high schools pioneered by Nikolaj Frederik Severin
Grundtvig). A 19th century theologian and social reformer, Grundtvig
wanted to create an educational system where anyone could obtain at
least some training in an employable skill and learn about Danish
history and culture at the same time. The youngest son will likely
follow in his older brothers footsteps when he completes his
conventional secondary school education.
Although, in the past, his scientific efforts have been focused
almost exclusively on improving treatment strategies for a variety of
cancers, Prof. Overgaard and many of his colleagues still question
whether aggressive therapy for some cancers is always in the best
future interest of the country as a whole. The Danish approach to the
management of prostate cancer is an obvious example.
In the United States, there is an overwhelming bias toward aggressive
therapeutic intervention for locally confined disease, and most
investigational protocols are designed to compare variations on the
themes of hormonal and/or radiotherapeutic or surgical interventions.
Yet it is only very recently that radical prostatectomy was
introduced into common practice in Denmark for the management of
localized prostate cancer.
The proper selection of patients for potentially curative
radiotherapeutic or surgical treatment is a topic of great interest
to Prof. Overgaard, as he explains: Im very proud of the
fact that weve been able to use hypoxic radiosensitizers and
other treatment modifications to achieve substantial improvements in
outcome for patients with head and neck cancer, for instance.
But for prostate cancer, which is certainly much more
common, he thinks it is very troublesome that we just
dont have enough information to decide who would really benefit
from treatment and who wouldnt, especially when you consider
the tremendous amount of health care resources involved in the debate.[14-16]
Truth Is Subjectivity
Visitors to Denmark who purchase durable goods for their personal use
do not have to pay the 25% sales tax required of Danish residents.
Tax rates such as these would be unacceptable to most Americans but
are necessary to support the gamut of Danish government-sponsored
programs, not the least costly of which is medical research. Of
course, Americans and others outside Denmark may take advantage of
the generous Danish taxpayers if they wish, since results of the
investigations are freely distributed internationally.
Hans von der Maase, professor of clinical oncology at Aarhus, with
his sharp Van Dyke beard and small round spectacles, would be well
cast as a scholar walking the cobblestone streets of Copenhagen
during its Golden Age in animated conversation with Grundtvig, Soren
Kirkegaard, Hans Christian Andersen, or any of the other luminaries
of that era.
It is relevant that one of the tenets of the existential philosophy
put forth by Kirkegaard at the time was the notion that truth
is subjectivity, ie, it is only the individuals active,
subjective belief in a certain idea that renders it true for that person.
Prof. von der Maase has learned from experience that this particular
existentialist concept might apply quite directly to the transfer of
medical knowledge from one country to another. He cites the example
of adjuvant therapy for stage I germ-cell tumors.
I used to go to the international meetings and engage in
sometimes heated discussions about what, if anything, would be the
best adjuvant therapy for early-stage germ-cell tumors, he
said. Even though we had performed randomized studies that
support the alternative of observation alone as an equivalent
strategy, there were always colleagues from other countries for whom
this choice just wouldnt fit into their belief system about how
to treat cancer. So now I just resign myself to knowing that there
are always things about which well simply have to agree to disagree.[17,18]
Whats considered a good approach to cancer treatment in Denmark
will certainly not always be viewed the same way in other countries.
But in their orderly 5-million-person clinical laboratory, the Danes
can be expected to continue to conduct thoughtfully designed
investigations seeking the most efficient and effective ways to treat
cancer. Oncologists elsewhere would ignore the results at their
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