Cancer treatment has always been carried out in the mode of first operation, then radiotherapy and chemotherapy, but this mode has fallen behind in the eyes of some experts at home and abroad.

The "reversal" of the concept of cancer diagnosis and treatment

First, the surgeon Zhu Zhenggang went around to "stop the knife"

There are countless diseases in the world, and the treatment of each disease must go through a long cognitive process to find a suitable, mature and scientific treatment. Now, the traditional treatment of cancer has undergone many reversals.

According to the past clinical and basic medical research, the medical community has concluded that the mode of cancer treatment is: first surgery, then radiotherapy, chemotherapy and now a new method-immunotherapy. Why can malignant tumors be operated, and the operation is the first choice? The medical profession believes that this is just like removing the mountain (the main body of the tumor) first, and then cleaning up the surrounding small clods with chemotherapy and radiotherapy. It is an effective treatment mode, which is called "tumor-removing surgery" academically.

Now, some experts at home and abroad think that this treatment mode is outdated, at least for patients with advanced cancer, it cannot be treated according to this mode. Zhu Zhenggang, an expert in the diagnosis, treatment and research of gastric cancer in the gastrointestinal surgery department of Shanghai Ruijin Hospital, suggested that patients with advanced gastric cancer should not be operated on, because patients with advanced gastric cancer will relapse soon after operation and their survival time is very short. On the contrary, we should take another method, chemotherapy first, then surgery.

This new concept and practice of treatment came out a few years ago abroad and is called "transformation therapy", which is based on clinical research. The new cancer treatment method subverts the traditional concept of cancer treatment, that is, first "transform" the tumor, turn the large tumor into a small tumor, and turn the late tumor into a middle stage or even an early stage, and then perform surgical resection.

The tumor transformation method before operation is chemotherapy. This new treatment method tried by Shanghai Ruijin Hospital is called "preoperative neoadjuvant intraperitoneal combined with systemic chemotherapy" (NIPS), which has been used for more than a year. The treatment results are surprising: the tumor cells that had spread in a large area disappeared, the ascites disappeared, and the fist-sized tumor was reduced to the size of a bean … A group of advanced patients underwent tumor resection after several courses of NIPS treatment, and the survival period was more than one year. Previously, doctors predicted that their survival time was only 3-6 months.

Based on this result, as a surgeon, Zhu Zhenggang went around to "stop the knife". He thought it was useless to rush to operate, and it would be counterproductive. Some doctors in Peking Union Medical College Hospital, Shanghai Zhongshan Hospital, Shanghai Cancer Hospital, Beijing Cancer Hospital and other big hospitals are also changing their concepts and not easily operating on patients with advanced gastric cancer.

Why do doctors such as Zhu Zhenggang believe that chemotherapy before surgery can better treat patients with advanced cancer? This is scientifically based, and it is the result of evidence-based medical treatment conducted by foreign doctors in clinic.

Second, the concept of evidence-based medicine holds that the credibility of expert opinions is the lowest.

Many diseases find the best treatment in the process of trial and error, and the above new treatment for gastric cancer was put forward only after obtaining the evidence, which involves a new concept of modern medicine-evidence-based medicine (medical treatment).

Evidence-based medicine means "evidence-based medicine", also known as empirical medicine, which is called evidence medicine in Hong Kong and Taiwan. It was put forward in 1996 by sakit, a clinical epidemiologist at the Evidence-based Medicine Center of the National Health Service Department, John Radcliffe Hospital, Oxford University, UK. The representative monograph is How to Practice and Teach Evidence-based Medicine. In the latest edition (2000 edition) of this monograph, sakit defined evidence-based medicine as "prudently, accurately and wisely applying the best research basis available at present, combining the personal professional skills of doctors and years of clinical experience, and considering the values and wishes of patients, and combining the three perfectly to formulate the treatment measures for patients".

The basic content of evidence-based medicine can be summarized as a core concept, two gold standard evidences, three basic elements, four basic steps and five-level evidence gradient.

A core concept is that doctors should stress and rely on evidence in treating diseases, and the evidence comes from the latest high-quality clinical research results, which is external evidence relative to personal experience.

However, the evidence is true or false, so it is necessary to have reliable or important evidence, that is, two gold standard evidence. One is the systematic review (RCT) of multiple randomized controlled trials, that is, systematic review or meta-analysis; The second is a randomized controlled trial with a large enough single sample (case), which are the most reliable evidence to prove the effectiveness and safety of a certain diagnosis and treatment method.

Three basic elements mean that clinicians should rely on three basic elements to formulate the best diagnosis and treatment plan for different patients, namely, the latest and best clinical research evidence collected, the doctor’s skilled clinical experience and the individual situation and wishes of patients.

The four basic steps are to ask questions in clinical practice, search for evidence all over the world, evaluate the latest and most comprehensive evidence collected, then apply the best evidence, and then evaluate the curative effect.

The five-level evidence gradient means that the research evidence is divided into five levels according to quality and reliability, and the strength of the evidence decreases in turn. The first level is a systematic review of all RCTs, the second level is RCTs with a large enough sample size, the third level is a non-randomized controlled study, the fourth level is an uncontrolled series of case observations, and the fifth level is an expert opinion.

Sakit believes that in clinical treatment, we should first consider the use of one or two levels of gold standard evidence, and in the absence of gold standard evidence, other levels of evidence can be used in turn, and expert opinions have the lowest credibility.

According to the above-mentioned concept of evidence-based medicine, there should be evidence for the treatment of advanced gastric cancer or other advanced cancers. According to the evidence of Ruijin Hospital, more than 30 cases of advanced gastric cancer have been treated by NIPS, and the success rate of surgical transformation has reached 70%, of which 77.8% have been completely removed. After conversion treatment, the survival time of patients has reached more than one year, and the quality of life is also good.

However, according to the second of the two gold standards of evidence-based medicine, that is, a randomized controlled trial with a large enough single sample (case), there are only more than 30 cases of evidence in Ruijin Hospital. Therefore, more cases are needed to prove the effectiveness of this treatment.

Third, the era of specialists working in isolation is out of date.

In the diagnosis and treatment of cancer, doctors should also follow the treatment guidelines formulated by medical professional associations, authoritative national medical research centers or authoritative national health administrative departments, which are also based on the results of evidence-based medical research.

NCCN is the abbreviation of American National Comprehensive Cancer Network. It is a non-profit alliance organization composed of 25 famous cancer centers in the world (including NCI in the United States). It publishes various clinical practice guidelines for malignant tumors every year. Because of its universality and authority, it has been widely recognized and followed by clinicians all over the world.

The Ministry of Health of China has also issued relevant guidelines for cancer diagnosis and treatment, such as the Guidelines for Diagnosis and Treatment of Gastric Cancer (2011 Edition).

However, in the clinical diagnosis and treatment, there are still many hospitals and doctors in our country who do not treat diseases completely according to the guidelines, but fight for their own treatment with their own clinical experience and specialty characteristics. Similarly, taking gastric cancer as an example, if patients with gastric cancer seek treatment in different departments of the hospital, such as surgery, oncology, radiotherapy, etc., these departments will treat the patients with surgery, chemotherapy and radiotherapy respectively, which does not meet the requirements of the guidelines for the diagnosis and treatment of gastric cancer and lacks the overall treatment concept.

In order to change this situation, the Sixth Affiliated Hospital of Sun Yat-sen University made a new attempt. They set up a multi-disciplinary clinic for gastric cancer, where specialists such as gastrointestinal surgery, oncology, radiotherapy, thoracic surgery, interventional department and pathology gathered together to discuss each case of gastric cancer and reach an agreement on the final diagnosis and treatment plan of the patients. This combined outpatient service can provide patients with personalized and optimized treatment plans, and is also suitable for the treatment of other cancers and diseases.

Xu Ting’s Death and Medical Choice

On the afternoon of September 7th this year, Xu Ting, a 26-year-old post-90s actress, died of malignant lymphoma in Beijing 304 Hospital, after several months of treatment.

Xu Ting’s death shows that in the face of cancer, human ability is still limited. However, if we actively treat cancer and choose appropriate treatment methods, we can still greatly reduce the mortality rate after cancer, and achieve the "three one-thirds" goal of cancer prevention and treatment put forward by the World Health Organization, that is, one-third of cancer can be prevented; One third of cancers can be found and cured early; One third of cancer patients can relieve their pain, prolong their lives and improve their quality of life through effective comprehensive treatment.

Xu Ting’s death shows that she didn’t even reach the latter 1/3 goal of the World Health Organization. Why? A large number of media reports have outlined the initial reason, which is the result of Xu Ting’s personal choice.

In May this year, a hospital in Nanjing initially diagnosed Xu Ting with cancer, but the whole family, including Xu Ting, didn’t believe it.

After that, on July 9th, Xu Ting exposed the examination reports from Beijing 301 Hospital and Beijing Cancer Hospital in Weibo, and all the examination reports from the two hospitals pointed to malignant lymphomas.

Although both hospitals advised her to undergo chemotherapy, Xu Ting refused after consideration. This is a choice based on Xu Ting’s personal life experience. This choice has also prompted Xu Ting to go to two forks in the road. One is that he does not intend to find out what kind of cancer he is suffering from through western medicine, and the other is that he is unwilling to undergo chemotherapy. Because she had seen Qin Sihan, the "most handsome traffic policeman in Chengdu", who suffered from leukemia chemotherapy, her hair fell out and she was weak, but she finally passed away. She believes that adopting western medicine treatment will lead to both human and financial resources.

In fact, Xu Ting suffers from T-lymphoblastic lymphoma, which is a very deadly malignant tumor. Although the treatment of this malignant lymphoma is controversial at home and abroad, it is agreed that combined chemotherapy and individualized treatment of autologous hematopoietic stem cell transplantation can make some patients get better therapeutic effect and longer survival time. However, Xu Ting chose Chinese medicine treatment based on his personal life experience, including cupping, scraping, acupuncture and bloodletting.

Chinese and Western medicine have their own characteristics and indications. Cupping and scraping are helpful to dispel fatigue. In this year’s Olympic Games, online celebrity has been transformed by American swimmer Phelps, but it is obviously not suitable for the treatment of T-lymphoblastic lymphoma, and it has no symptomatic effect. Acupuncture helps to relieve pain, but bloodletting has not been proved to be effective for any specific disease so far. Therefore, these methods are totally different for the treatment of Xu Ting’s disease, and even seek fish from the edge of the wood.

Although Xu Ting didn’t always be stubborn, he finally returned from the fork in the road and received chemotherapy. The results of chemotherapy completely refuted her personal experience. She didn’t lose her hair like Qin Sihan and her weight didn’t change. And has a preliminary curative effect.

However, it’s all too late. Xu Ting received chemotherapy only one week before his death. According to the experience of clinicians, T-lymphoblastic lymphoma will spread far away in the early stage, invading bone marrow and central nervous system. Therefore, even early patients should be treated as stage IV (advanced stage) for chemotherapy. Before she died, Xu Ting’s mother asked her if she regretted chemotherapy now. She said, regret it! This is enough to explain the problem.

Xu Ting’s death certainly illustrates the danger of cancer, but it is also extremely important to adopt what kind of treatment plan after suffering from cancer. The question is, who will spread the correct knowledge of cancer prevention and treatment to Xu Ting and the thousands of Xu Ting in Qian Qian? This is the most important thing.

Lessons from the surge of cancer patients after September 11th.

On September 11th, 2001, the Twin Towers of the World Trade Center in New York were attacked by a passenger plane hijacked by terrorists, which had disastrous consequences.

Fifteen years later, for Americans, the haze of 9/11 still lingers, because the surge in the number of cancer patients alone has frightened Americans. Affected by dust and other pollutants from the collapse of the Twin Towers, the number of firefighters, police, sanitation workers, volunteers and residents near the World Trade Center who participated in the ground rescue reached 5,441. Moreover, about 75,000 people suffered other health damage due to the September 11th terrorist attacks.

About half of these 5441 cancer patients are between 55 and 64 years old, suffering from various cancers, the most important of which are thyroid cancer, leukemia, lung cancer, esophageal cancer and prostate cancer.

In this regard, there was a statistic. As early as 2012, the Journal of the American Medical Association published a study done by the new york Municipal Health Bureau. They counted more than 55,000 people who had been exposed to the dust in the ruins, among whom 1,187 people had been diagnosed with cancer, and the cancer incidence rate was about 21.58/100,000, while the total cancer incidence rate in the United States was 3 million/100,000. Moreover, compared with today’s 5,441 cancer patients and more than 55,000 people exposed to dust from the ruins, the incidence of cancer is higher, at 98.92/100,000. Obviously, it is an indisputable fact that the September 11th incident caused a surge in cancer patients, and there are many lessons to be learned, the most important of which is the lesson of social medicine, that is, for political reasons, exposing innocent people to high-concentration polluted environment.

After the incident, in order to let the world see that the United States is strong and will not be intimidated and crushed by terrorist attacks, the government came forward to appease the public and encourage people to go to work. The US Environmental Protection Agency, the Safety and Health Committee and other departments all came out to assure the public: "The air is safe and you can breathe with confidence; Water is safe and safe to drink. "

The American public later realized this, especially cancer patients pointed out that the government was more concerned about the economic situation, and they needed to maintain the position of the United States as the world economic center, and new york was one of them.

However, we should know that the World Trade Center in new york, built in 1966, used a lot of chemical materials such as asbestos. The terrorist attacks triggered a fire, with 1.2 million tons of high-strength and high-density building materials burning, including 300-400 tons of asbestos released from the North Tower. In addition, there are more than 50,000 computers in high-rise buildings, which also release a lot of harmful substances after burning.

In this regard, American journalists cooperated with the investigators of the American Geographical Association to come up with a dust sample that was different from the US government’s statement. It was found that after the terrorist incident, the dust in the center of new york contained a large number of harmful substances such as asbestos, lead, man-made fibers and polycyclic aromatic hydrocarbons, which were highly corrosive, and their alkaline strength was equivalent to that of household cleaners.

The World Health Organization has already announced that chemicals such as asbestos and lead are highly carcinogenic. After the terrorist attacks, the government immediately encouraged people to go to work, which undoubtedly exposed the public to extremely high concentrations of carcinogens, laying a curse for the high incidence of cancer in the future.

In fact, after the disaster, the governments of many countries will take the way of concealing the truth, encouraging or even requiring the public to work in a heavily polluted environment and live in a polluted place, instead of taking measures to evacuate the public from the polluted place, thus pushing more innocent people into danger. For example, in order to bid for the right to host the 2020 Olympic Games, in September 2013, Japanese Prime Minister Shinzo Abe said in support of Tokyo’s bid for the Olympic Games: Despite the nuclear leakage at the Fukushima Daiichi nuclear power plant after the March 11, 2011 earthquake and tsunami in Japan, the environment is "under control". At that time, there were many voices in Japan accusing Abe of being untrue, because the development of the situation was not as Abe said, but the pollution of nuclear power plants was difficult to remove, and polluted groundwater and sewage were continuously discharged into the sea.

At the same time, Tokyo Electric Power Company (TEPCO) of Japan has also acted up and down, saying that nuclear pollution can be controlled. Moreover, because the company did not inform people of the specific details of the nuclear leakage in time, even the drinking water and bathing water of American rescuers stationed in Japan may be polluted. Some American soldiers even drove helicopters to Fukushima for disaster relief.

After understanding the truth, more than 400 people who participated in the earthquake and tsunami rescue in Japan in 2011 sued Tokyo Electric Power Company, claiming that they suffered from leukemia, brain tumor and various cancers due to radiation, demanding compensation. At present, this lawsuit is still in progress.

The U.S. government is still unwilling to admit the fact that the number of people suffering from cancer has increased sharply after the September 11 terrorist attacks, but requires scientific research to confirm it.

In fact, everyone knows that when air and water contain a lot of pollutants, people who work and live in this environment will inevitably increase their chances of getting cancer. Therefore, encouraging the public to work and live in a polluted environment is undoubtedly a second harm to people before the pollutants have been completely eliminated and the environment has not been restored to a safe state. The lessons of the September 11 incident in the United States are worthy of serious learning by all countries. (Zhang Tiankan)