Abstract

Prior to the early 20th Century, surgical resection was the only option for management of the patient with cancer. The discovery of radium in 1898 and the subsequent observation of the effects of nitrogen mustard in WWI led to the development of alternatives or additives to surgery. Early pioneers in the development of both radiation and chemotherapy included a number of personnel from our institution. Progressively, options in cancer care became multidisciplinary.

With advances in diagnosis and molecular characterization of tumors and the development of large databases to identify prognosis and predict outcome, multidisciplinary care became essential. This resulted in a volume of knowledge that was not discipline dependent. Most importantly, regardless of the territorial aspirations of clinicians in various disciplines, the patient clearly identified that it was the disease that he or she was facing that needed addressing. The downside of this is the loss of autonomous care and the patient runs the risk of drowning in a sea of consultants with no one physician assuming leadership responsibility.

The expanded complexity of available individual care results in care we cannot afford for all. This includes our over utilization of technology and a willingness to use expensive drugs or technologies in the presence of minimal benefit.

To address the complexities of these issues, the primary step is to become transparent about cost, benefit, side effects, and the limitations of care. We must define and educate patients as to what they can and cannot expect. The subtle perception that life and death are alternatives to be manipulated must be replaced by a more realistic appreciation of what we can and cannot provide.