Let’s imagine you could turn the clock back to 1984 and peek into an oncologist’s waiting room. You’d see patients with big hair and shoulder pads, looking at magazines instead of smartphones. At the front of the room, you’d see a receptionist typing away on the latest and greatest computer technology: an Apple IIe. You might hear Duran Duran playing on the radio. But you wouldn’t hear anyone being scheduled for an MRI, laparoscopic surgery or even a biopsy, and it’s unlikely you’d see a patient smiling after a test result. In fact, if you came back week after week, you’d stop recognizing the patients. That’s because, 30 years ago, practically everything to do with cancer treatment – from diagnosis to surgery to chemotherapy – was on the verge of a revolution.
As a result of major improvements in diagnosis and treatment, patient outcomes have drastically improved, says Dr. Peter Venner, former director of medical oncology at the Cross Cancer Institute. When he began practising medicine in 1980, a man with prostate cancer (his treatment specialty) would have been treated with hormone therapy and expected to live just two years. “Now, it is probably beyond five years because of new treatments,” he says.
In fact, almost every cancer you can think of – including breast, lung, colorectal and gynecological cancers – have much higher survival rates these days. “Part of this relates to better, earlier diagnosis, so there’s better screening taking place, but there’s also better treatment,” Venner says.
In the early 1980s, a patient with cancer symptoms would have approached his family doctor with a health complaint, just like today – but the similarities in treatment would have ended there. Instead of being sent for an MRI or CT scan to look for signs of cancer, a patient would have been sent for an X-ray – one of the only imaging techniques available, offering only a very basic view of the inside of a person’s body. Ultrasound technology – which offers a clearer view of the body’s tissues without the radiation of an X-ray – was still in its infancy and wasn’t in common use for many more years. “All the tools we take for absolute granted now were just not available,” says Dr. Sandy McEwan, former director, oncologic imaging at the Cross Cancer Institute.
He explains that it wasn’t until the middle of the ’80s that computerized tomography (CT) scans began to be used consistently, offering doctors a tool to more accurately pinpoint the location of a tumour and guide procedures like surgery, biopsy and radiation therapy. The device uses computing technology to analyze a series of X-ray views of the body, taken at different angles, to create cross-sectional images. A few years after that, magnetic resonance imaging (MRI) – a device that involves magnetic fields and radio waves – became ubiquitous, allowing doctors to get an even clearer view of a patient’s internal organs, especially the brain and spinal cord.
In the mid-1990s, positron emission tomography (PET) scanning became routine, but it didn’t come to Alberta until 2002. This screening tool requires patients to swallow, inhale or be injected with a radioactive drug that allows the device to capture information about chemical activity in the body. It’s a useful tool for diagnosing some cancers.
A big reason for the advancement in these technologies is computing power, which has improved immeasurably over the years, says Venner. As a result, doctors can get to the bottom of a patient’s complaint much faster than ever before. “We can diagnose cancer earlier and find metastatic spread earlier,” he says. Imaging technologies also help clinicians conduct a biopsy, in which a portion of tissue is removed and examined under a microscope for signs of cancer. All of this has improved patient outcomes.
SLICE OF LIFE: Advancements in technology over the past three decades have meant that survival rates for certain cancers, such as Dr. Peter Venner’s treatment specialty, prostate cancer, are much higher.
Photo by Ryan Girard
Thirty years after Venner started working at the Cross Cancer Institute, the number of beds has dropped from about 100 to 56, even though the population of the province has swelled. It isn’t because of health care cutbacks or the opening of new facilities, but because most people who come to the clinic are now outpatients. Over the years, the side effects of chemotherapy and radiation have lessened dramatically, and people are well enough to return home after their treatments. “A lot of our medication used to cause nausea and vomiting,” he says. “Now, we can be confident in telling patients that nausea and vomiting is less common and less severe than it used to be.” This is largely because of pharmaceutical advances. “You could almost count on your hand the number of drugs available to cancer patients in the ’70s and ’80s,” he says. Now, there are probably 100.
Surgical treatment has seen some drastic improvements, says Dr. Claire Temple-Oberle, a surgeon with the Tom Baker Cancer Centre in Calgary. “I think a general theme is ‘Less is more,’” she says. Over the last couple of decades, the surgical removal of cancerous tissue has become much more precise, resulting in smaller amounts of tissue being removed. A plastic surgeon specializing in breast reconstruction and surgery for melanoma, Temple-Oberle explains that it used to be common practice for surgeons to excise melanoma with a large margin, to be sure all of the cancer had been removed. Now, they take a very different approach: “Research shows taking less is easier on patients and has better results.”
The actual surgical techniques have also evolved. When she started practising medicine in 2003, skin grafting was crude and typically involved removing layers of skin from the thigh and transplanting it where the melanoma once was. Because the surgical areas were fragile, a patient would be laid up in bed for three weeks. Now melanoma is removed with a “keystone flap,” a surgical design that looks a bit like a keystone in an arch, and doesn’t require any skin grafting. Patients can walk afterwards and recover much faster.
Better surgical techniques also mean that patients whose cancer has spread to their lymph nodes aren’t automatically subjected to the removal of all of their lymph nodes, which can result in painful swelling in the arms and legs. Now, doctors can do a lymph biopsy to identify the cancerous nodes and then remove them.
Improvements in drugs also mean that patients with late-stage melanoma don’t always need surgery. “Before, the treatments were aggressive,” she says. If a patient had melanoma spreading down the skin of their legs or arms, they might need to have a limb amputated or have a limb perfusion, a procedure involving injecting a high dose of chemotherapy into a vein. A relatively new drug called interleukin 2 (or IL-2) can spare a patient from these treatments.
Much of Temple-Oberle’s work involves recreating breast tissue in women who’ve had mastectomies. Over the last decade, plastic surgery techniques have improved to the point where breasts created by a surgeon look real enough to pass “the change room test.” It’s even possible, sometimes, for a surgeon to save a woman’s original nipples and transplant them onto the new breasts. The number of surgeries needed to recreate breasts has also decreased (from two to just one) and it’s possible to do the reconstruction at the same time as the mastectomy, although this still rarely happens. On average, only six per cent of Canadian women having mastectomies get reconstructive surgery at the same time; at the Tom Baker Centre, 25 per cent of women have the reconstruction at the same time (one of the highest rates in the country).
Better outcomes mean happier patients – but there’s also more attention being paid to the overall wellness of patients. In the last five to 10 years, more attention has been paid to how satisfied cancer patients are with the care they receive, says Temple-Oberle. In the breast cancer realm, two questionnaires – the BRECON-31 and BREAST-Q – have been developed to measure this.
There are also more resources to help a patient deal with the psychological impacts of the disease, like support groups, counselling services and programs like Look Good Feel Better (which helps women with cancer manage their physical appearance while they’re ill). Patients have better access to supportive therapies (like massage and nutrition counselling) to help them manage their symptoms, as well.
And while many patients do recover, thanks to the improvements in treatment, there’s more available to help those who won’t. “Thirty years ago, we didn’t really have a hospice in Edmonton,” says Venner. “We now have a large number of hospice beds.” This frees up room in the hospital to care for other cancer patients and ensures that palliative patients have the support they need to be comfortable and die with dignity. “We have specialists providing this care – nurses, psychosocial support, pharmacists – in the community and in the hospice, and it’s now a specialty in medicine.”
Something to Talk About
Today, Albertans rally around cancer patients and research
Jane Weller remembers a time when cancer didn’t come up in polite conversation. Even when her school friend’s mother died of cancer, it was never acknowledged. “No one talked about Doris’s mom,” she says. “Even if someone in your community had cancer, you didn’t talk about it.”
Almost three decades later, things have changed dramatically. Cancer patients and their families no longer stay silent about the disease. “People now stand up to cancer,” says Weller, who has worked at the Alberta Cancer Foundation for 26 years. In 1988, Albertans donated $500,000 annually to our Foundation; that number has now sky rocketed to $48 million. “We’ve come together as a community to support Albertans throughout their cancer journey,” she says.
These fundraising dollars have made a huge impact on both patient care and research. A $5-million donation from The Dianne and Irving Kipnes Foundation was instrumental in establishing the Edmonton PETCentre at the Cross Cancer Institute – now one of the most advanced imaging centres in the country, helping both patients, clinicians and researchers. It’s just one example of how donors are helping Alberta maintain world-class cancer treatment facilities, says Weller.