Treatment Following Cancer
Norman L. Higinbotham, M.D., C.M. , F.A.C.S.
Editor's Note: A comprehensive report of a special study conducted by New York University Child Prosthetic Studies on the "Survival and Prosthetic Fitting of Children Amputated for Malignancy," by C.B. Taft and Sidney Fishman, appeared in the February 1966 issue of the ICIB. The following two reports comprise a follow-up to the NYU study. The papers upon which these reports are based were presented at a recent conference on research needs in cancer rehabilitation jointly sponsored by the Institute of Physical Medicine and Rehabilitation, the Memorial Hospital for Cancer and Allied Diseases, and the Vocational Rehabilitation Administration. They are reprinted with permission from Rehabilitation Record, Vol. 7, No. 1, January-February 1966.
Between 1930 and 1965, 1,116 patients of the Bone Service at Memorial Hospital have been subjected to amputation of some form or another, from the loss of a finger or toe to hemicorporectomy.
This represents a good deal of mutilating surgery--and that from only one of many large institutions treating cancer in this country. On the basis of these cases alone, we have ample evidence of the need of abundant rehabilitation, and more and better rehabilitation, and more accessible rehabilitation.
In many respects, amputation for cancer poses a quite different problem from that for accidents or infection. In the first place, the cancer patient is usually fully aware of his diagnosis. He knows that he has a potentially lethal disease which may take his life despite prompt and adequate treatment. He knows the sword of Damocles hangs over his head, and he lives in constant fear that his cancer may recur or spread as he has seen it do in some of his relatives or acquaintances. His hopes must be bolstered and he must be kept occupied in hopeful pursuits both for himself and for others or he will surely sink in the slough of despondency.
Most of the amputations in cancer patients are major or high amputations. Very few of our cases are below the knee or elbow. The provision of prosthetic devices is thus quite difficult.
All ages are involved. The management of the young child is quite at variance with the management of the geriatric patient. Both must be considered in the overall rehabilitation process. Even with the very young, it is our practice to "talk it over"--to explain what we are required to do and what the patient will be like after the operation. The way to rehabilitation is thus already begun. The patient enters each progressive phase of postoperative care early ambulation, physiotherapy, group therapy, and prosthetic replacement with understanding and enthusiasm.
It is too often a custom for the surgeon to operate and then rest on his laurels, ensured of the gratitude of patient and family for a lifesaving procedure. He is usually too little aware of, or interested in, the facilities available for rehabilitation. Our first job is to make surgeons throughout the country aware of the existing facilities. Second, we must encourage them to avail themselves of the opportunity presented by these facilities to benefit their patients. Third, we must persuade them to follow through diligently, in cooperation with the rehabilitative service for an extended period, even years.
It must be one of the functions of this conference to arouse surgeons from their ingrained lethargy. The general surgeon is the target (I speak feelingly, for I am a general surgeon). He is the one most apt to be involved in the problem. As a rule, because of his training, he sees beyond the unique orthopedic problem presented and is able to look upon the cancer patient as a whole.
Rehabilitation should begin on the surgeon's first contact with the patient when amputation is being only considered. The patient's interests that can be played upon, his awareness of his problem and its implications, his philosophy of life in general, and his hopes and faith in the future can all be gingerly explored. Calisthenic exercises can be instituted to develop muscles he will soon be depending more upon. He is thus prepared for his momentous decision and is more amenable to reason. After the operation, when other specialized activities are begun, he will have learned to trust the veracity and humanity of those responsible for his care.
Let us not lose sight of the cancer patient who has a poor chance. He is entitled to just as much consideration as the high percentage case. After all, in our medical inexactitude, the low percenter may outlive the high percenter and do a better job of working and living while he remains alive with his presumably lethal disease. A prosthesis should be provided as though a cure was anticipated, despite the published and the quoted statistics of the survival rate for the specific malignant disease.
Furthermore, in order to try to prolong life in comfort, it is sometimes expedient to amputate an extremity, upper or lower, involved with metastasis (spreading) from a primary cancer in the breast, lung, kidney, or elsewhere. Patients in these circumstances as a rule present a rather hopeless situation from the standpoint of a 5-year cure and usually survive an average period of 18 months. But the occasional patient may continue under suitable control for 5 years, or even 10. These, too, merit our every earnest endeavor in rehabilitative aid.
The Most Radical Procedure
Hemicorporectomy-the surgical removal of the lower half of the body-can reasonably be described as the most radical of operations.
Two men-both in their midforties--who underwent this surgery in 1964 at New York's Memorial Hospital for Cancer and Allied Diseases, have recently concluded rehabilitation programs at the Institute of Physical Medicine and Rehabilitation.
Both men were in advanced stages of bladder cancer at the time of their surgery. They faced 6 months of agonizing pain and then certain death-- or hemicorporectomy. They both chose the surgery. As Dr. Howard A. Rusk, Director of IPMR, describes the operation, it entails "amputation of both lower extremities, the pelvis, the genitalia, and the rectum."
After surgery, the two men were put through intensive physical therapy and rehabilitative training at IPMR. Part of that training was learning to sit erect in plaster of Paris body casts, and learning to make the transfer from bed to cast without help.
The lightest type of balsa wood was used in making unique prostheses, weighing about 7 pounds each. In them, the two men learned to stand erect, walk, and even climb stairs. Both learned to drive and now are licensed
to operate their own cars. One is in graduate school taking courses in vocational counseling, while the other is ready to return to his job in the office of a New York labor union.
Dr. Rusk estimates that the surgery which saved the lives of these two could likewise save nearly a third of the close to 10,000 women who die each year of cervical cancer, as well as many of the 20,000 persons who annually succumb to colon and bladder cancer.
Clinics Participating In Child Prosthetic Research Program
Editor's Note; Since the last roster of clinics participating in the Child Prosthetic Research Program was published in the April 1965 issue of the Inter-Clinic Information Bulletin, two additional clinics have been accepted into the program. Some changes in personnel and meeting times have also taken place. The following listing represents the status of participating clinics as of March 31, 1966.
Norman L. Higinbotham, M.D., C.M. , F.A.C.S. is Attending Surgeon at the Bone Service Memorial Hospital for Cancer and Allied Diseases New York, N.Y.