In recent years, the people see a doctor, and add a fear of overtreatment.
Overtreatment, as the name implies, refers to the treatment given by physicians to patients “over the top”, more than the treatment needs of the disease, such as drug doses with a large, drug varieties with more, treatment “grade” over the standard, the treatment time dragged out, the surgical program set too much, and so on. And so on. Due to the failure to master the “right degree” of treatment, such treatment often leads to different degrees of adverse consequences.
I. Liver cancer is the “hardest hit” by over-treatment
Once upon a time, liver cancer was called the “king of cancers” because of its poor curative effect and poor prognosis. In the past 20 years, joint multidisciplinary research has been carried out for the clinical treatment of liver cancer, and there are new theoretical breakthroughs and various treatment modalities have emerged, with nearly 20 kinds of leapfrog improvements. Because liver cancer often requires the combined application of multiple treatment methods to achieve satisfactory curative effects, coupled with the fact that people’s understanding and mastery of liver cancer are still far from satisfactory level, coupled with factors such as interest-driven, the comprehensive treatment of liver cancer often evolves into the superposition of multiple treatment modalities, leading to huge waste and excessive side effects, forming excessive treatment and making it difficult to achieve the expected clinical curative effects. Therefore, the clinical treatment of liver cancer is the “easy place” for overtreatment. In addition, the absolute number of liver cancer patients in China is large, and the clinical treatment of liver cancer in China can be said to be the “disaster area” for overtreatment, which deserves high attention from both doctors and patients.
II. Over-treatment of liver cancer is the most important thing to avoid
As we all know, liver cancer often occurs and develops on the basis of chronic liver disease or even cirrhosis. The liver reserve function of liver cancer patients is often reduced to different degrees, and the liver function of many liver cancer patients has been severely damaged and is on the verge of failure.
A lot of clinical practice shows that the recent and long-term efficacy of hepatocellular carcinoma and the survival quality of hepatocellular carcinoma patients depend largely on the liver function status. If the liver function is poor, it is difficult to have good curative effect even if the liver cancer is well treated (except in the case of liver transplantation); if the liver function is still good, it is easy to produce satisfactory clinical effect in treatment; therefore, the treatment of liver cancer must protect the liver function to the greatest extent. The importance of protecting liver function in the treatment of liver cancer is aptly described by the phrase “if you keep the green hills alive, you are not afraid of having no firewood to burn”. The reserve function of liver is the “green hill” of liver cancer patients, so the treatment of liver cancer should avoid “burning the hill” as much as possible, let alone “destroying the hill”.
The second reason why liver cancer should not be over-treated is due to the complication of portal hypertension on top of cirrhosis. Not only liver cancer patients often have impaired liver function, but portal hypertension is also a common complication. Even if liver cancer is well treated, if the degree of portal hypertension is further aggravated and upper gastrointestinal hemorrhage occurs, the patient’s life will be seriously threatened; even if the upper gastrointestinal hemorrhage does not occur, the aggravation of hypersplenism may lead to Even if upper gastrointestinal bleeding does not occur, hypersplenism may lead to low white blood cells and further impairment of immune function, which will undoubtedly accelerate the recurrence of liver cancer and make the treatment counterproductive.
As a result, the treatment of liver cancer should be “right rather than left” and should not be excessive!
3. Dialectical understanding of excessive treatment
According to dialectical materialism, the concept of overtreatment should be relative and evolving. Therefore, it cannot be said absolutely that a certain treatment plan is overtreatment and vice versa.
. Overtreatment is relative
Due to the uneven development of medical institutions in China, there are great differences in technology and equipment conditions between different regions and different hospitals in the same region. This situation inevitably leads to the phenomenon that what is considered a reasonable treatment in one hospital may be considered obsolete in another hospital in the same region; what is considered a reasonable treatment plan in one region may be considered overtreatment in another region; of course, the above-mentioned relativity of overtreatment also exists between different countries.
To illustrate. A liver cancer of about 5 cm in diameter that grows at the margin, we usually choose laparoscopic hepatectomy, or radiofrequency ablation of liver cancer; if it grows in the middle of the liver, we usually use CT-guided transdermal radiofrequency ablation of liver cancer as the treatment option. These two options represent the modern progress and development trend of liver cancer treatment, with less damage, good protection of liver function, fast postoperative recovery, repeatable application, satisfactory near and long-term efficacy, and the efficacy of most patients is at least comparable to surgical resection. Compared with these two options, the traditional open liver resection appears to be more traumatic, more damaging to the liver, more costly, and seems to be “killing the chicken with a bull’s-eye”, which is suspected of over-treatment. However, these two advanced options require either specialized laparoscopic techniques or expensive radiofrequency ablation equipment, and many hospitals in China do not have these techniques and equipment. For such a case, a conventional liver resection carried out in a slightly less well-equipped hospital could still be considered moderate treatment, and classification as overtreatment would be far-fetched.
Like technique and equipment, the patient’s ability to support himself financially can be deduced as relative to overtreatment. For patients with good economic conditions, treatment plans can be developed with a greater focus on efficacy, using a combination of tools with the aim of achieving better outcomes. However, the cost of such a program can be as little as 50,000 (RMB) or as much as 100,000 or even more, which would be excessive for a patient with poorer economic conditions.
It can be seen that overtreatment is relative and should be analyzed specifically in relation to factors such as the level of technical equipment of the hospital and the economic level of the patient.
The concept of overtreatment is evolving
With the development of medical science and technology and the accumulation of clinical experience, the standard of overtreatment should be changed accordingly. Take a patient with right-sided hepatocellular carcinoma as an example, the cancer is only 3 cm in diameter and close to the middle of the liver. 20 years ago, the best surgical option for this particular case was right hepatectomy, which completely removed the hepatocellular carcinoma, but the patient also lost more than 50% of the liver. After the major surgery, the patient would need to “pass through five hurdles and six generals”, overcome many complications and pass through a long dangerous period. Such a medical procedure was considered normal at that time, representing the advanced medical technology level at that time, and was never suspected of over-treatment.
In the last decade, local treatment modalities such as radiofrequency therapy for hepatocellular carcinoma have come into being, and the efficacy of interventional embolization therapy has also been substantially improved. For the above-mentioned cases, the application of these non-hepatic resection means can easily achieve clinical efficacy superior to that of traditional liver resection. Under the current medical technology, it would be over-treatment to treat the same cases with the same “big cut and cure” as 20 years ago.
The correct treatment plan and principles in the past only reflected the medical level at that time, while the current treatment plan for liver cancer should be fully integrated with modern treatment concepts and technologies.
Overtreatment of liver cancer mainly includes some aspects
1.”Killing a chicken with a bull’s-eye”
Generally speaking, liver transplantation > liver resection > interventional embolization > local treatment such as radiofrequency. In the treatment of liver cancer, as long as the clinical benefits are similar, we should try to use less traumatic treatment methods. In our hepatobiliary center, most liver cancers less than 5 cm in diameter are treated by minimally invasive methods such as radiofrequency or interventional embolization. If the tumor is located in the middle of the liver, it is treated by radiofrequency through skin liver puncture; if the tumor is located at the edge of the liver, it is treated by laparoscopic radiofrequency. If imaging suggests that the tumor has a richer arterial blood supply, then treatment is done by interventional embolization. From the perspective of minimally invasive and protecting the reserve function of liver, it is really “killing the chicken with a bull’s-eye” to treat these small liver cancers by lobectomy or segmental resection. Of course, if the liver function reserve is very poor, even though the liver cancer is small, we should still consider liver transplantation, which is not considered killing the chicken with a bull’s eye.
2. “Emphasis on eliminating evil, light on helping righteousness”
The dialectical relationship between “eliminating evil” and “helping righteousness” has been clearly discussed by ancient medical scholars in China. Unfortunately, in the modern treatment of liver cancer, it seems that such a low-level mistake of “emphasizing evil, but not supporting righteousness” has not been completely eliminated.
In foreign countries, when patients with middle and advanced liver cancer receive chemotherapy and embolization, the amount of drugs used is lower than that in China, and the variety of drugs used is relatively single. In China, in order to kill cancer cells to the greatest extent, some scholars still advocate “high dose” and “multiple varieties” of drugs, and believe that the therapeutic effect is proportional to the amount of chemotherapy drugs.
The “heavy-duty” treatment leads to obvious damage to liver function and reduced immunity, which reduces the quality of life of patients and does not prolong their survival at all, but only allows them to change their “walking” method.
”The treatment often exceeds the tolerance of the body and the needs of the disease itself, which can be described as a complete over-treatment.
3.Reliance on liver transplantation blindly
If the liver is cancerous, it would be fine to replace it with another one. Such a cult of liver transplantation has given birth to a considerable amount of over-treatment, and liver transplantation has been done for patients who should not be transplanted.
Yes, liver transplantation is indeed an effective means of treating liver cancer, which can not only maximize the removal of liver cancer cells, but also effectively remove the virus and cure cirrhosis and portal hypertension. Theoretically, liver transplantation is an ideal means to treat liver cancer in the context of cirrhosis.
However, liver transplantation for the treatment of liver cancer also has significant limitations. After liver transplantation, in order to prevent the new liver from being rejected by the organism, sufficient immunosuppressive drugs need to be applied to suppress the immune function of the organism. When the body’s immune function is suppressed, cancer cells that have metastasized to other parts of the body before surgery will grow rapidly, leading to the recurrence of liver cancer.
As we can see, liver transplantation is not suitable for all liver cancers. Only patients with small liver cancers without extra-hepatic metastases are most suitable for liver transplantation. For those larger liver cancers with intravenous, pulmonary or other metastases, systemic recurrence will occur within 6 months after liver transplantation and death will occur within a short period of time.
4. Ignore the economic status
A reasonable plan is not necessarily the most scientific, but it must be the most humane. The consideration of patients’ financial ability should never be ignored when formulating treatment plans. To sum up, the treatment cost of liver cancer is large and the long-term efficacy is poor. Unless there is a fuller assurance of the long-term efficacy of the patient, try not to cure to the situation of dumping the family’s money. Such a situation where people are left with no money often means that it is difficult for the patient’s family to make ends meet, and on a moral level, such a treatment plan seems inhumane! It should be classified as overtreatment.
5.More is better
It is an objective rule that things are inevitable, and so is the clinical treatment of liver cancer. It is common sense that if a treatment is effective for hepatocellular carcinoma, repeated application can strengthen the curative effect. However, this does not mean that the treatment can be repeatedly applied without limitation. In clinical practice, we often see patients applying interventional embolization for 8 or even 10 times, but reviewing the data of each treatment, it is easy to see that the first 3 treatments are the most effective, the 4th and 5th treatments are also effective, and the effect of the 6th treatment is not so obvious. Not only the efficacy is not obvious, but also led to considerable side effects, and this situation can not escape the suspicion of overtreatment!
6.Blindly copying
When patients have liver cancer, they usually ask around about other liver cancer patients, especially those with good curative effect, hoping to learn from others’ successful experience to achieve twice the result with half the effort. Although this is a common practice, it should not be done blindly.
There is a Western proverb that “one person’s food may be another person’s poison”, which is an appropriate analogy to the choice of liver cancer treatment. Patients with liver cancer should choose the most appropriate treatment according to their own condition, including the size, location, differentiation, liver function reserve and economic status of liver cancer, etc. They should not copy the successful treatment plan of others. Too many “successful experiences” will be too much for your liver to “digest” and lead to too many side effects.
V. Postscript
After writing the above article in one breath, I feel relieved to have the opportunity to present the words that have been pressed in my mind for a long time to the majority of liver cancer patients and their families, and to “wake up” and “protect” their treatment, which is my greatest wish. At the same time, I am happy and feel guilty. Overtreatment of liver cancer is by no means a new thing, and it is not an isolated phenomenon. Today, I am concerned about overtreatment, to some extent, as a reflection and realization of my past work. But I would like to take this article as a wish for the future and a blessing to the patients.