New ovarian cancer treatment

WHEN I MET MRS. PRAVDOWICZ, SHE couldn't eat. She couldn't walk, couldn't stand, couldn't even turn over in her bed. She could barely even breathe. For four months, Mrs. Pravdowicz's belly had been swelling as the rest of her wasted away. Short of breath and always tired, she'd been forced to quit her job cleaning houses. A week before, she had quit cleaning herself. Her landlord had found her lying on soiled sheets, looking like a balloon with a head and limbs. He brought her to the hospital where I work--Cook County Hospital, last hope for generations of Chicago immigrants. I knew only the sketchiest details of her life. Mrs. Pravdowicz had arrived from Poland a few years earlier. She was 57 years old and a widow, and she spoke no English.

The internists who had evaluated Mrs. Pravdowicz had eliminated several conditions. It was clear that she wasn't pregnant. Her CT scans showed that a watery fluid filled her abdomen and half of her left chest. The condition, called ascites, can be caused by cirrhosis, or inflammation of the liver. But Mrs. Pravdowicz's blood tests had shown no signs of liver malfunction, despite weeks of treating herself with a Polish folk remedy made mainly of vodka. Ascites can also be caused by heart or kidney failure, but Mrs. Pravdowicz's test results had shown that her heart and kidneys were normal.

From her X-rays and CT scans, the internists saw that Mrs. Pravdowicz's right ovary had been overtaken by a tumor the size of a grapefruit. They had suspected ovarian cancer, but they couldn't be sure. Doctors use the word tumor to describe any unusual mass of tissue. As a gynecologic oncologist, a doctor who specializes in cancers of the female genital tract, I would have the job of figuring out whether Mrs. Pravdowicz had cancer. And if it turned out that she did, I would have to determine the source of the cancer and how best to fight it.

My residents and I transferred Mrs. Pravdowicz to our ward and began work. Our first priority was to ease her breathing. As the fluid in her belly had accumulated, her abdomen had become so tense that her diaphragm could barely move. Mrs. Pravdowicz had to move air in and out of her lungs using only her chest muscles, and they were tiring. In fact, the fluid in her belly had seeped into her left lung, causing it to collapse. By inserting a syringe into Mrs. Pravdowicz's abdominal cavity, we were able to drain the fluid and allow the lung to reexpand. And the next morning we withdrew seven liters of bloody brown fluid from her belly.

But within two days Mrs. Pravdowicz's belly was swollen again, and she was no better, only more dehydrated. Still, we'd made a little progress. We had sent samples of the fluid for lab tests, and the results confirmed what we clinicians had guessed: Mrs. Pravdowicz had cancer.

Cancer that spreads into the abdominal cavity usually comes from one of only a few sources. To plan an attack, we had to pinpoint the source of the disease. If Mrs. Pravdowicz's cancer had originated in another organ and spread to the ovaries, it might be so extensive that surgery could not slow its spread. We would have to examine Mrs. Pravdowicz's internal organs to find out. Before we began I tried to reassure Mrs. Pravdowicz, but I'm afraid she had little faith in doctors she couldn't understand.

Using a tube that allowed us to look inside Mrs. Pravdowicz's gastrointestinal tract, we inspected the lining of her stomach, duodenum, and colon. We found no sign of cancer. Mammograms and a physical exam failed to turn up a breast tumor. The CT scans had shown no sign of pancreatic cancer. The odds pointed to the swollen ovary as the source of Mrs. Pravdowicz's cancer.

OVARIAN CANCER IS AMONG THE most insidious and deadly of cancers. Lung cancer kills more people, but the links between smoking and lung cancer are well known. Breast cancer, too, is more common, but it can often be cured. Ovarian cancer is stealthy. By the time it is diagnosed, the cancer is usually so advanced that roughly 85 percent of the patients die within two years. Each year about 15,000 American women die of the disease.

Early on, the symptoms are ascribed to almost anything else: gallstones, constipation, midlife weight gain, neurosis. The cancerous spread begins when malignant cells burst out of the ovary, slough off, and seed the surfaces of the abdominal cavity. As the cancerous tissue grows, it ruptures tiny lymph-filled capillaries. This fluid distends the abdomen and leaks into the chest cavity, slowly filling the space in which the lungs expand and contract. Eventually the cancerous growth can squeeze the bowel shut.

Before doctors had the tools of chemotherapy and radiation, they tried to carve cancer out with a knife. Unfortunately, it is nearly impossible to remove all the cancerous cells. A surgeon can cut out a cancerous ovary, but by the time the patient has recovered, often the cancer has, too. In frustration, surgeons have tried cutting out more and more tissue, excising the gut, the spleen, lymph nodes, the belly lining, and bits of liver, only to find them caked with cancerous cells. The lesson they learned from such measures is that the more radical the surgery, the longer it took for the cancerous cells to grow back, and the longer the women lived. That innovation--removing as much cancerous tissue as possible during the first operation--is now the traditional treatment for ovarian cancer.

But that treatment wasn't devised for someone in Mrs. Pravdowicz's condition. As an undocumented alien, she had worked off the books, saving up cash to return to Poland in her old age. When she developed symptoms that would have driven other women to a doctor, Mrs. Pravdowicz stayed at home, uninsured and terrified of deportation. When she was brought to the hospital, her cancer was so advanced that she was on the verge of death.

Still, surgery could be done. Surgery is always possible; it's the recovery that is tough. I could excise Mrs. Pravdowicz's ovaries and as much malignant tissue as possible. But I couldn't predict the outcome. She would either recover well enough to receive chemotherapy or suffer overwhelming complications and die.

I knew of an alternative. Three months before, I'd been party to a new approach: chemotherapy before surgery. Another Polish woman had come in for treatment. She too had had ascites and ovarian cancer. Although she had been operated on in Poland, the surgeons had been cautious. They had done only a biopsy of the ovaries and a quick examination of her organs. Then she had received six months of chemotherapy. After her treatment ended and she moved to the United States, she came to my hospital seeking surgical treatment for her cancer. I performed the operation that should have been done when she was first diagnosed. When I examined her ovaries, I was surprised to find that the cancer had shrunk into masses of scar. I was able to remove it all.

That patient did so well because of advances in chemotherapy. The current strategy for fighting ovarian cancer was developed 20 years ago, when neither chemotherapy nor radiation alone worked very well. Drugs back then weren't very effective, and radiation that could kill the tumor could kill the patient as well. Today new drugs like tamoxifen and cisplatin have revolutionized chemotherapy. When they are given after surgery, these drugs can eradicate all signs of the patient's cancer. Unfortunately, all too often the cancer grows back within a few years--this time more resistant to the drugs. But immortality is a gift of the gods, not of doctors. Most patients now have a window of time in which to grieve, grow back their hair, and savor the life that's left to them.

When a group of senior oncologists gathered to discuss Mrs. Pravdowicz's case, I told them how my other patient had done well with chemotherapy before surgery. They dismissed her outcome as anecdotal, unverified, unreliable. The discussion was brief. The consensus was for surgery, then chemotherapy. Elegant studies had proved the effectiveness of that strategy 20 years ago. It was standard. It was traditional.

In medicine, tradition is the sum of the successes, errors, and failures of generations of doctors. It is proven. It is uncontroversial. And it is safe. But today's traditions developed from yesterday's science, and yesterday's science is obsolete. Science feeds on change. It asks new questions and demands new answers. So science challenges old traditions, overthrows them, and sets up new traditions. Yesterday's wild innovations are the medicine we practice today.

For clinicians, the difficulty comes in deciding when to challenge established practice. Wait too long for rigorous proof, and patients die needlessly. But change practices in the wrong direction and the result is the same. Innovation may be noble, but it isn't always safe.