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'Repairing the World'

'Repairing the World'

If you are like me—closer to retirement than midcareer—after years of coping with the tragedies of patients with cancer, you are being jolted by the occurrence of malignancies or other serious illnesses in close friends. In response, we might be inclined to reassess the rewards of whatever cancer work we do. There's a case to be made for what could be a radical change in at least some of what we do: We should find other ways to use our skills to "repair the world." A translation of the Hebrew phrase "tikkun olam," repairing the world suggests social action and the pursuit of social justice. In particular, I urge considering some foreign service.

The global challenges of cancer are not a mystery: The case burden is growing rapidly. Beyond surgery when appropriate, few interventions are practical—that is, widely applicable—and inexpensive. Large differences in incidence/mortality ratios exist within and among countries. The costs of optimal treatments are great, and the financial resources available in most countries are very limited.

Additionally, attempts to address these challenges constructively must be made in the face of extensive social injustice, eg, political terrorism and lawlessness, cultural extremism, racism, class discrimination, gender discrimination, market and religious terrorism, and poverty. In these daunting circumstances, can we actually "repair the (cancer) world"?

I submit that practicing oncologists have medical and teaching skills and expertise with which much can be done. At the individual patient care level, here is what I have seen on many visits to Asia and Africa:

Basic history-taking and physical examination skills are undervalued and poorly exercised. Present me with five patients who have "limited stage" breast cancer in a resource-poor 'country, and I will find one who has suspicious cervical or pathologic supraclavicular adenopathy. At the bedside of a young Asian woman, I was asked to help decide about the operability of her clinical stage III breast cancer. Beginning a rapid evaluation, I found tachypnea and tachycardia, subsequently demonstrated to be due to pleural and pericardial meta'static disease. Indeed, I have often found evaluations for metastatic cancer halted prematurely because radiologic imaging of the skeleton or brain could not be accomplished, when patients' verbal reports strongly suggested that such procedures were unlikely to be revealing.

The limits and appropriate use of our therapies are often unrecognized. In Nigeria, I saw a hypoxic patient with confluent pulmonary metastases from breast cancer who was considered to have a life expectancy of 6 to 18 months. A colleague of mine in India asked me to see a woman with locally advanced breast cancer. He had consulted by e-mail with specialists in the United States and had been giving her neoadjuvant chemotherapy. The patient entered the examination room with a basketball-sized but operable tumor in her breast. Clearly, neoadjuvant treatment had been unneccessary.

Basic aspects of supportive care are omitted. A nurse colleague and I were visiting a frightened Tagalog-speaking woman awaiting surgery for breast cancer in the Philippines. To the astonishment of the Philippino patient, my nurse, a breast cancer survivor herself, unbuttoned her blouse showing her mastectomy scar and held out her fingers to indicate "8 years." The Philippino woman beamed, visibly reassured by the offer of support. In lieu of formal psychosocial counseling, such gestures become all the more meaningful.


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