Author reply

Abstract

We thank Dr. Rayson for expressing interest in the concept of Tenju-gann (pronounced “ten-JEW-gan”) and welcome the opportunity to respond to his comments. Dr. Rayson suggests that the concept of Tenju-gann deserves broader application to diseases among the young and the middle-aged, because the vast majority of advanced solid cancers in these age groups are refractory to therapy. It is naturally very conceivable that the Tenju-gann mind-set might be of great help in reconciling patients and family members to terminal disease, regardless of age, and assist in treatment decisions to allow a “peaceful death with minimal suffering.” We should make every effort to minimize a cancer patient's physical, psychologic, and social burdens. The more widespread development of caring and affordable hospice organizations is urgently needed, and emphasis on palliative care is essential. In these matters, we completely agree with Dr. Rayson. However, whereas the mind-set of Tenju-gann applies to all age groups, the concept as defined can be applied only to those in old age. We would like to explain our thoughts further to clarify a different nuance of the issue. This will be done first from a Japanese perspective and then from a wider perspective. Tenju in Japanese means “healthy, long life,” which is, in traditional Japanese thought, given by heaven to every person at birth. With this concept as the background, we can celebrate when a person has experienced Tenju without encountering or having to deal with serious diseases or accidents. Within the boundaries of this term, a line should be drawn between mere fatalism and the Tenju concept. Most importantly, care should be taken that the Tenju-gann concept not be exploited by therapeutic nihilists. In Japan, in recent years, a book entitled Patients, Don't Fight Against Your Cancer!, written by a radiologist, became particularly popular. The author correctly pointed out the problematic attitude of some surgeons and medical oncologists who perform aggressive treatments in the simplistic subjective belief that those treatments are beneficial, without either objective proof or concern about the patient's quality of life. However, the strong and to some extent inaccurate statements expressed in the book, combined with repeated indiscriminate coverage in the press, has caused a worrisome nihilism among people in their attitudes toward therapy. A tendency now exists among some cancer patients to avoid not only appropriate medical treatments, but also even health checks for early detection of cancer. The backlash clearly has had negative consequences for many cancer patients and for Japanese society in general. Many people feel that cancers, including those occurring in patients of young age, are inevitable. However, there have been many situations in which various types of cancer became preventable and stopped occurring. Others are becoming preventable and declining in their occurrence. Examples of both are occupational cancers, gastric carcinomas, hepatocellular carcinomas after hepatitis B or C virus infection, and squamous cell carcinomas in smokers. Thus, we should be generally optimistic about preventing, or at least delaying, the onset of cancer. Possible cancer development in people with hereditary predisposition could also be eventually avoided or lessened by sophisticated genetic counseling or improved treatment in earlier phases of the disease. Moreover, advanced techniques for diagnosing cancers at an early stage and improved accessibility to those techniques should significantly improve the rate of permanent cure. Subjects treated successfully for primary cancers could develop second and third primary cancers, but recurrence could be well managed. It is no longer rare to see complete cure in cases of multiple cancers. According to Buddhist teaching, heaven gave a life span of about 120 years to humans. L. A. Loeb calculated that prostate carcinoma would develop at the late age of 130 years if the mutation rate could be diminished to half the current rate. Of course, this provides a reason for general optimism, but it needs to be supported by efficacy and progress in cancer prevention as well as improved early diagnosis and treatment. Within the broadest definition of “treatment,” we include mental and psychologic treatment in a manner that allows us to reach the goal of Tenju-gann. Tomoyuki Kitagawa M.D.*, Takashi Sugimura M.D. , * The Cancer Institute of the Japanese Foundation for Cancer Research, Tokyo, Japan, National Cancer Center, Tokyo, Japan