Time to remove the terms ‘aggressive’ and ‘radical’ from the medical lexicon
In my speciality of oncology things can get pretty emotive. After all, when it comes to cancer we are dealing with life on death. Famously Nixon declared war on cancer and that war, along with many personal battles, continues to this day.
In keeping with the emotive nature of the war on cancer we use language that reflects war. Treatments, especially surgery, are frequently described as aggressive or radical, e.g. radical prostatectomy or modified radical mastectomy. Medical therapies are now called targeted therapies as though be remote control the doctor can target the drone and its’ weaponry to the cancer.
These terms do in some cases do accurately describe the personal attitudes of practitioners: some are more aggressive (or proctive) and others more conservative. However, the use of therse terms for the description of individual procedures is not justified.
My main practive is in treating peritoneal surface disease – cancer that infiltrates the peritoneal cavity. This can be treated by removing all of the cancer and in the case of many units we administer heated chemotherapy into the abdomen at the time of the operation. Because the surgery is a big, long operation and can be associated with significant morbidity it is often called aggressive or radical. There is even a committee being established in New South Wales to oversee ‘radical peritonectomy surgery’.
The clear counter argument to calling this surgery radical is ovarian cancer surgery. Ovarian cancer is traditionally treated with total abdominal hysterectomy and bilateral salpingo-oophoerctomy or removing the womb and ovaries. This is accompanied by omentectomy. Generally, when conducted by most gynaecological oncologists any disease in the upper part of the abdomen is left behind – in other words all of the cancer is not removed. There approach ignores research that demonstrates that women who have surgery to remove all of the cancer including cancer in the upper abdomen have better survival and not much more morbidity than conventional surgery. The operation required is complete cytoreduction or what we commonly call peritonectomy.
So should we call complete, or shall we say ‘adequate’ surgery for ovarian cancer ‘radical’ or ‘aggressive’ surgery? We could, but then we might also want a descriptor for the traditional operation: some options could be ‘complacent’, or ‘inadequate’, or ‘lazy’ or ‘conservative’ cytoreductive surgery.
We should aim to get our terminology right as some patients will end up choosing less radical but also less effective treatment.