How do people die from cancer? You asked Google heres the ...

https://www.theguardian.com/commentisfree/2016/aug/17/how-d...

How do people die from cancer? You asked

Google heres the answer
Ranjana Srivastava
Every day millions of internet users ask Google lifes most difficult questions, big and
small. Our writers answer some of the commonest queries
Wednesday 17 August 2016 09.00BST

ur consultation is nearly nished when my patient leans forward, and says, So,
doctor, in all this time, no one has explained this. Exactly how will I die? He is
in his 80s, with a head of snowy hair and a face lined with experience. He has
declined a second round of chemotherapy and elected to have palliative care.
Still, an academic at heart, he is curious about the human body and likes good
explanations.
What have you heard? I ask. Oh, the usual scary stories, he responds lightly; but the
anxiety on his face is unmistakable and I feel suddenly protective of him.
Would you like to discuss this today? I ask gently, wondering if he might want his wife
there.
As you can see Im dying to know, he says, pleased at his own joke.
If you are a cancer patient, or care for someone with the illness, this is something you
might have thought about. How do people die from cancer? is one of the most
common questions asked of Google. Yet, its surprisingly rare for patients to ask it of
their oncologist. As someone who has lost many patients and taken part in numerous
conversations about death and dying, I will do my best to explain this, but rst a little
context might help.
Some people are clearly afraid of what might be revealed if they ask the question. Others
want to know but are dissuaded by their loved ones. When you mention dying, you
stop ghting, one woman admonished her husband. The case of a young patient is
seared in my mind. Days before her death, she pleaded with me to tell the truth because
she was slowly becoming confused and her religious family had kept her in the dark.
Im afraid youre dying, I began, as I held her hand. But just then, her husband
marched in and having heard the exchange, was furious that Id extinguish her hope at a
critical time. As she apologised with her eyes, he shouted at me and sent me out of the
room, then forcibly took her home.
Its no wonder that there is reluctance on the part of patients and doctors to discuss
prognosis but there is evidence that truthful, sensitive communication and where
needed, a discussion about mortality, enables patients to take charge of their healthcare
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How do people die from cancer? You asked Google heres the ...

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decisions, plan their aairs and steer away from unnecessarily aggressive therapies.
Contrary to popular fears, patients attest that awareness of dying does not lead to greater
sadness, anxiety or depression. It also does not hasten death. There is evidence that in
the aftermath of death, bereaved family members report less anxiety and depression if
they were included in conversations about dying. By and large, honesty does seem the
best policy.
Studies worryingly show that a majority of patients are unaware of a terminal prognosis,
either because they have not been told or because they have misunderstood the
information. Somewhat disappointingly, oncologists who communicate honestly about a
poor prognosis may be less well liked by their patient. But when we gloss over prognosis,
its understandably even more dicult to tread close to the issue of just how one might
die.
Thanks to advances in medicine, many cancer patients dont die and the gures keep
improving. Two thirds of patients diagnosed with cancer in the rich world today will
survive ve years and those who reach the ve-year mark will improve their odds for the
next ve, and so on. But cancer is really many dierent diseases that behave in very
dierent ways. Some cancers, such as colon cancer, when detected early, are curable.
Early breast cancer is highly curable but can recur decades later. Metastatic prostate
cancer, kidney cancer and melanoma, which until recently had dismal treatment
options, are now being tackled with increasingly promising therapies that are yielding
unprecedented survival times.
But the sobering truth is that advanced cancer is incurable and although modern
treatments can control symptoms and prolong survival, they cannot prolong life
indenitely. This is why I think its important for anyone who wants to know, how cancer
patients actually die.
Failure to thrive is a broad term for a number of developments in end-stage cancer
that basically lead to someone slowing down in a stepwise deterioration until death.
Cancer is caused by an uninhibited growth of previously normal cells that expertly
evade the bodys usual defences to spread, or metastasise, to other parts. When cancer
aects a vital organ, its function is impaired and the impairment can result in death. The
liver and kidneys eliminate toxins and maintain normal physiology theyre normally
organs of great reserve so when they fail, death is imminent.
Cancer cells release a plethora of chemicals that inhibit appetite and aect the digestion
and absorption of food, leading to progressive weight loss and hence, profound
weakness. Dehydration is not uncommon, due to distaste for uids or an inability to
swallow. The lack of nutrition, hydration and activity causes rapid loss of muscle mass
and weakness. Metastases to the lung are common and can cause distressing shortness
of breath its important to understand that the lungs (or other organs) dont stop
working altogether, but performing under great stress exhausts them. Its like constantly
pushing uphill against a heavy weight.
Cancer patients can also die from uncontrolled infection that overwhelms the bodys
usual resources. Having cancer impairs immunity and recent chemotherapy compounds
the problem by suppressing the bone marrow. The bone marrow can be considered the
factory where blood cells are produced its function may be impaired by chemotherapy

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How do people die from cancer? You asked Google heres the ...

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or inltration by cancer cells.Death can occur due to a severe infection. Pre-existing liver
impairment or kidney failure due to dehydration can make antibiotic choice dicult,
too.
You may notice that patients with cancer involving their brain look particularly unwell.
Most cancers in the brain come from elsewhere, such as the breast, lung and kidney.
Brain metastases exert their inuence in a few ways by causing seizures, paralysis,
bleeding or behavioural disturbance. Patients aected by brain metastases can become
fatigued and uninterested and rapidly grow frail. Swelling in the brain can lead to
progressive loss of consciousness and death.
In some cancers, such as that of the prostate, breast and lung, bone metastases or
biochemical changes can give rise to dangerously high levels of calcium, which causes
reduced consciousness and renal failure, leading to death.
Uncontrolled bleeding, cardiac arrest or respiratory failure due to a large blood clot
happen but contrary to popular belief, sudden and catastrophic death in cancer is rare.
And of course, even patients with advanced cancer can succumb to a heart attack or
stroke, common non-cancer causes of mortality in the general community.
You may have heard of the so-called double eect of giving strong medications such as
morphine for cancer pain, fearing that the escalation of the drug levels hastens death.
But experts say that opioids are vital to relieving suering and that they typically dont
shorten an already limited life.
Its important to appreciate that death can happen in a few ways, so I wanted to touch on
the important topic of what healthcare professionals can do to ease the process of dying.
In places where good palliative care is embedded, its value cannot be overestimated.
Palliative care teams provide expert assistance with the management of physical
symptoms and psychological distress. They can address thorny questions, counsel
anxious family members, and help patients record a legacy, in written or digital form.
They normalise grief and help bring perspective at a challenging time.
People who are new to palliative care are commonly apprehensive that they will miss out
on eective cancer management but there is very good evidence that palliative care
improves psychological wellbeing, quality of life, and in some cases, life expectancy.
Palliative care is a relative newcomer to medicine, so you may nd yourself living in an
area where a formal service doesnt exist, but there may be local doctors and allied
health workers trained in aspects of providing it, so do be sure to ask around.
Finally, a word about how to ask your oncologist about prognosis and in turn, how you
will die. What you should know is that in many places, training in this delicate area of
communication is woefully inadequate and your doctor may feel uncomfortable
discussing the subject. But this should not prevent any doctor from trying or at least
referring you to someone who can help.
Accurate prognostication is dicult, but you should expect an estimation in terms of
weeks, months, or years. When it comes to asking the most dicult questions, dont
expect the oncologist to read between the lines. Its your life and your death: you are
entitled to an honest opinion, ongoing conversation and compassionate care which, by

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How do people die from cancer? You asked Google heres the ...

https://www.theguardian.com/commentisfree/2016/aug/17/how-d...

the way, can come from any number of people including nurses, social workers, family
doctors, chaplains and, of course, those who are close to you.
Over 2,000 years ago, the Greek philosopher Epicurus observed that the art of living well
and the art of dying well were one. More recently, Oliver Sacks reminded us of this tenet
as he was dying from metastatic melanoma. If die we must, its worth reminding
ourselves of the part we can play in ensuring a death that is peaceful.
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