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The Cheerful Oncologist discusses the Abraham Cherrix case

The Cheerful Oncologist, noting my recent post about the relapse of Abraham Cherrix’s lymphoma in the lung, has done an analysis from–of course!–an oncologist’s viewpoint. Given that I don’t treat lymphoma, other than doing the occasional lymph node biopsy to diagnose it, his viewpoint is well worth reading.

He quite correctly points out that Abraham’s reasoning, where he observes that his tumor has “only” recurred in one place and concludes that what he’s doing is working is the fallacy of moderation. He points out that for Hodgkin’s lymphoma (and, I personally would add, for all cancer), it’s all or nothing, kill or die. Eliminating just some of the tumor is not good enough:

Using Mr. Cherrix’s reasoning, then, position A is “The cancer has not returned, therefore my treatments have worked” and position B is “The cancer has relapsed throughout my body, therefore my treatments have failed.” Position C, the middle ground position, would thus be “My cancer has only come back in one area, therefore my treatments have worked on most of my cancer.” Why do I consider this to be fallacious logic?

The answer is because patients with active relapsed Hodgkin lymphoma do not live long; unlike other chronic illnesses Hodgkin disease kills if it is not killed itself. There is no middle ground; no partial credit is given for eliminating some of the tumor.

Sadly, this is quite true. It’s also the reason that a chemotherapy that eliminates 99% of the cancer cells is often not good enough to cure the cancer. All it takes is for a single cancer cell to survive. He also points out, as I have in the past, that it is possible to cure relapsed Hodgkin’s lymphoma using radiotherapy alone, which, given that the other treatments Abraham has chosen, is in essence all that he is getting for his recurrent cancer. However, studies suggest that this is only possible in patients who had early stage disease, a good intial response to first line therapy, and no involvment of organs other than lymph nodes with cancer. Abraham does not fit at least two out of those three criteria. The Cheerful Oncologist also points out that a time to relapse of less than a year and lung involvement are both poor prognostic indicators for salvage by radical radiotherapy alone. I can’t help but note that Abraham has both features, and he is not even getting “radical” radiotherapy. Rather he’s getting some sort of minimalist low dose “targeted” radiation therapy.

Basically, as I have pointed out before Abraham and his radiation oncologist are just playing Whac-A-Mole with his cancer (or, as The Cheerful Oncologist calls it, “spot-weld” radiation therapy), irradiating tumor deposits as they pop up. This will work in the short term, as Hodgkin’s lymphoma is a radiosensitive tumor, but it won’t eliminate the microscopic tumor deposits throughout his body that are responsible for these recurrences. Eventually one of two things will happen: Either multiple tumors will pop up over an area that is too large to be safely radiated, or a tumor will pop up in a previously radiated part of his body. When that happens, if he refuses chemotherapy he will die. Even if he accepts it then, his chances will have decreased so much that he would still probably die.

The Cheerful Oncologist recommends, as I have also recommended, high dose chemotherapy with stem cell rescue. Even with that, his odds of long term survival aren’t that great, but they’re virtually zero with the regimen he is using now.

( The Cheeful Oncologist’s full discussion.)

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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