Moving the Chains

One of the goals of modern cancer therapy is to pound away at a tumor with different tools in an attempt to prolong life - to turn cancer into a chronic disease. Ironically, this exposes the patient to a Hobson's choice of suffering from the effects of treatment, or from the cancer if its growth is not thwarted. The fine line between helping and harming a patient is one of the oldest dilemmas in cancer care and must be considered in every move the doctor makes in the contest against a clever foe. A good oncologist must become a strategist, an expert at seeing the playing field before him, a master interpreter of the opponent's plans and a genius in calling the best play, so to speak, to ensure victory.

That's right - an oncologist is basically a football coach in a lab coat.

The fight against cancer is obviously not taken as sport, but like the clashes that occur on cool, sunny afternoons in October it is a match between two adversaries. Similar to the fall pastime, each head coach has his game plan before him and rallies his team with shouts of inspiration, asking his players to give their all for the cause. Unlike a football game, though, when the coach says "Now go out there and kill 'em!" he really means it. Playing against cancer is the ultimate death match.

With a little imagination one can envision how the game develops:

First, think of the oncologist as the coach whose team has the football on the 20 yard line in overtime. The distant end zone, where victory lies, represents either cure of the patient or at least prolongation of life. The team has only four downs to go the required 80 yards, otherwise possession changes, and cancer has never failed to score when given the ball. The four downs allotted the Crab Busters represent the four stages in a patient's plan of therapy. Each down can be described as follows:

First down - this is the time to call the best play in the book, for some initial treatments can wipe out cancer like a fullback plowing through the crowd at a garden party. Some tumors, like testis cancer or Hodgkin disease, are so susceptible to chemotherapy one can call a quarterback sneak and still reach the end zone. Many others, though, require a more complicated strategy involving fake handoffs and long passes. The goal on first down is to gain as much of the necessary yardage as possible.

Second down - if the team doesn't score with the preferred treatment, the oncologist must now take a hard look at his clipboard and pick the second best therapy he has. No two patients are alike, and therefore salvage treatments do vary. The coach must take into consideration such factors as the patient's overall condition before sending in the play. Some second down plays are simply straight forward rushes, such as single-agent chemotherapy; others such as stem-cell transplantation for relapsed lymphoma, are works of subterfuge and precision as beautiful as a successful flea-flicker.

Third down - by now if the tumor has not been outplayed the chance of fans joyously tearing down the goalposts dwindles. Although some cancers such as ovarian carcinoma respond to many different kinds of chemotherapy and can be subdued for years, most others, like an enemy coach who decodes the other team's signals, become resistant. This is the down where experimental therapy should be considered. The playbook has been exhausted - it is now time to innovate, such as drawing a saber from the folds of the uniform, or setting the field on fire.

Fourth down - as sad as it seems, there comes a time when the oncologist must realize that he can no longer prevent a tumor from achieving its perverted goal of committing suicide by killing its host. In many cases there is nothing more to be gained by exposing the patient to the side effects of a futile Hail Mary pass. A more humane move would be to refer the patient for hospice care and begin to concentrate on providing quality of life, rather than obsess over its length. A few patients will not accept this advice and will seek out unproven cancer therapies. While an oncologist should respect the wishes of his patients, he is not required to advocate any treatment not supported by medical evidence.

A skilled oncologist, like a hard-nosed football coach, knows when to play it conservative and when to go for broke. He plots his strategy against the enemy and then stands on the sideline as the drama unfolds, hoping for the best, but unable to enter the playing field. The patient alone must carry the ball, and his doctor must always remember that the greatest coach is the one who embraces his players in victory or defeat and says "You did your best."