美國癌症協會主席出書談癌症的終結

When I was doing my medical training nearly 20 years ago, there were two kinds of residents: those who were planning on specializing in oncology and those who couldn’t tolerate the subject for even a month. One night when I was on call, I worked with someone in the second camp. He told me about a patient of his, an elderly woman with pancreatic cancer that had grown into her bile duct and metastasized through her intestinal tract. She had been through several rounds of chemotherapy without success and was ready to quit treatment, but was afraid to tell her oncologist. “She told me, ‘I don’t want him to think I’m giving up,’” my colleague said, obviously disgusted that she didn’t feel comfortable speaking freely about her goals.

近20年前，我還在接受醫學培訓，那時有兩種不同類型的住院醫生：一種人立志獻身於腫瘤學，而另一種人卻連專注這個專業哪怕一個月的時間也無法忍受。有一天晚上正值我當班，我和另一個人一起工作。他給我講了他的一名患者的故事：那是個患有胰腺癌的老年婦女，癌症已經擴散到了膽管，並經由腸道轉移了。她接受過數輪化療都沒有成功。她打算放棄治療，卻不敢對她的腫瘤醫師明言。“她跟我說：‘我不想讓他覺得我放棄了，’ ”我的同事說，語氣中很明顯地透露出他對她不能自在地抒發心願而感到不快。

He encouraged her to choose hospice care. Two weeks Later, he said to me, his patient’s hospice aide came up to him on the ward. “She told me that my patient made her promise that the day she died, she would come find me and tell me. She said my patient wanted to thank me for encouraging her to die the way she wanted to.”

他鼓勵她選擇臨終關懷，兩週後，她的臨終關懷助理來到他負責的病房。“她（那助理）告訴我，她是應那患者的要求而來：她答應會在她死去的那天來找我，並給我帶話。她說，我的患者很感激我對她的鼓勵，這才讓她得以按照自己希望的方式死去。”

I thought of this story at various points while reading “The Death of Cancer,” Vincent DeVita Jr.’s fascinating if hubristically titled new book, co-authored with his daughter, Elizabeth DeVita-Raeburn, a science writer. Today, more than four after President Nixon declared war on cancer and with so many new weapons in our arsenal supported by big budgets and a decidedly aggressive posture, when is it O.K. to give up? When is it best ?

我在讀小文森特·德維塔(Vincent DeVita Jr)和女兒——科普作家伊麗莎白·德維塔-雷伯恩(Elizabeth DeVita-Raeburn)合著、書名狂妄的趣作《癌症之死》(The Death of Cancer)的過程中，這個故事不時地在我腦海中浮現。今天，距離尼克松總統向癌症宣戰已有四十多年，秉持果斷進取的姿態，藉助雄厚資金的支持，我們已經擁有了很多對抗癌症的“新武器”， 那麼，到什麼地步放棄治療纔不會感到遺憾？何時纔是宣佈投降的最佳時機？

DeVita himself has been one of the top commanders in this war. He was in the vanguard of chemotherapists, engineering the first cure for Hodgkin’s disease and diffuse large B-cell lymphoma. Later, he was director of the National Cancer Institute, physician in chief at Memorial Sloan Kettering Cancer Center in Manhattan and president of the American Cancer Society.

德維塔本人一直是抗癌戰爭的最高指揮官之一。他是資深的化療專家，參與創建了第一個可治癒霍奇金淋巴瘤和瀰漫性大B細胞淋巴瘤的療法。後來，他擔任了美國國家癌症研究所(National Cancer Institute)的主任，曼哈頓紀念斯隆-凱特琳癌症中心(Memorial Sloan Kettering Cancer Center)的主任醫師，以及美國癌症協會(American Cancer Society)的主席。

In DeVita’s telling, we are winning this war. Childhood leukemias are now almost completely curable. Death rates for almost all types of cancers are steadily decreasing. We have an array of new biological molecules and immunotherapies that put the old slash-and-burn cancer drugs to shame. When he says, “We have the tools to eradicate cancer,” he is someone we should listen to.

按照德維塔的話來說，我們正在贏得這場戰爭。小兒白血病現在基本上已經可以完全治癒。幾乎所有類型的癌症的死亡率都在穩步下降。我們如今擁有衆多足以令舊的“刀耕火種”型癌症藥物汗顏的新型生物分子和免疫療法。所以，他說“我們已經掌握了根除癌症的工具”，這話當然有很高的可信度。

At this point many doctors would advocate a purely palliative approach, but not DeVita. Early in his career, he writes, he learned a “profound” lesson: “never to give up on anyone.” He finds another treatment, an experimental vaccine and a monoclonal antibody, but Lee has severe side effects. He is then put into another study, but the experimental treatment fails to achieve remission. By then the cancer has spread to his lungs and bones. He is given another experimental drug but develops severe diarrhea as a side effect. He becomes dehydrated and has to be admitted to the hospital, where an oncologist decides to try another combination of drugs, a decision DeVita calls “courageous.”

到了這個時候，很多醫生會建議患者接受姑息療法，但德維塔並沒有這樣做。他寫道，在他的職業生涯早期，他就已得到了“深刻的”教訓：“永遠不要輕易放棄任何人。”他又找到了其他的治療方法：一種實驗性疫苗和一種單克隆抗體，但李先生出現了嚴重的副作用。然後，李先生又參與了一項別的研究，但該實驗性治療也未能緩解其病情。此時，癌細胞已經擴散到了他的肺部和骨骼。他接受了另一種實驗性藥物，可副作用又來了：他嚴重腹瀉，因爲脫水，他只能入院治療。醫院的腫瘤科醫生決定再試試另一種藥物組合，連德維塔都稱這一決定“勇氣可嘉”。

Lee’s cancer is kept at bay for almost a year, but it recurs with a vengeance. However, DeVita isn’t done. He tries to get Lee one more experimental drug, abiraterone, but the company that manufactures it and guidelines from the Food and Drug Administration refuse to allow it to be used in patients with prostate cancer that is so far advanced. Without further options, Lee is finally admitted into hospice care and dies two weeks later at home. “It was awful to watch,” DeVita writes. “I kept thinking about the treatments Lee didn’t get.”

李先生的癌症得到了控制，可惜還不到一年，它再度爆發了。德維塔仍不肯就此罷休。他試圖讓李先生再試用一種新的實驗性藥物——阿比特龍(abiraterone)，但生產該藥物的公司和美國食品和藥品監督管理局(Food and Drug Administration)的指南都不允許將其用於終末期前列腺癌患者。此時李先生終於別無選擇，只得轉入臨終關懷機構，兩週後在家中去世。“目睹這一切真讓人難受，”德維塔寫道，“我一直對李先生沒能獲得的治療念念不忘。”

Despite my uneasiness with DeVita’s take-no-prisoners strategy, I thoroughly enjoyed his book. He gives an authoritative review of the history of surgery and radiation therapy. His depictions of the behind-the-scenes search for new cancer drugs and the turf wars between radiation, surgical and medical oncologists are dishy and fascinating. He tells many poignant anecdotes, like one about a 10-year-old cancer patient who gives DeVita a 50-cent piece because he puts in her intravenous line on the first try. Ultimately, DeVita ably shows that the development of oncology as a modern specialty is a very human story.

儘管德維塔絕不罷休的治療策略讓我不太舒服，但我還是非常喜歡他的這本書。他對手術和放療的歷史做出了權威的回顧，介紹了尋找新型抗癌藥物的幕後故事，描寫了放療、外科和內科腫瘤學家間的激烈交鋒，讀來引人入勝。他講述了許多令人心痛的往事，譬如一個10歲的癌症患者曾經給他50美分，因爲他在給她靜脈注射扎針時一次就成功了。總而言之，德維塔精妙的文筆，讓你覺得自己並非是在閱讀腫瘤學作爲一門現代專業的發展歷程，而是在聆聽一個非常人性化的故事。

But in the end I would have liked to see more about palliative care: when to give up the good fight. In the case of his friend, DeVita writes that a study published two years after Lee died showed that patients with advanced prostate cancer treated with abiraterone were living longer. He calls it a “near miss” — if Lee had lived two more years, he could have been one of those patients. But he doesn’t mention that the abiraterone-treated patients lived only 3.9 months longer than they otherwise would have.

只是歸根結底，我還是希望能看到更多關於姑息治療的內容，譬如，什麼時候可以放棄與癌症戰鬥？以他的朋友爲例，德維塔在書中寫道，在李先生去世兩年後發表的一項研究顯示，接受阿比特龍治療的晚期前列腺癌患者生存期較長。他感嘆這“真是緣慳一線”——倘若李先生當初能夠挺過兩年以上的時間，他本可以成爲這些患者中的一員。可是他並沒有提到，接受阿比特龍治療的患者也僅比不治療多活了3.9個月而已。