Under What Circumstances Is Prophylactic Cancer Removal Surgery Necessary?
Over the weekend just past, I accompanied a cousin (a niece of my uncle) and her husband to Peking Union Medical College Hospital, where we booked a special-needs expert appointment. Our main purpose was to ask an expert from PUMCH to help us judge whether this cousin should undergo pancreatectomy to prevent pancreatic cancer.
Actually, before the visit, based on her medical records, I had already clearly stated that she absolutely should not have a pancreatectomy. But earlier, a second-level professor specializing in the pancreas had strongly advised her to have immediate pancreatectomy. That professor is a pancreatic specialist at a well-known Class-A tertiary hospital, holding the title of second-level professor.
Laypeople may have no concept of the title “second-level professor” in hospitals. In China, professors are divided into four levels; academicians of the two national academies are first-level professors, and second-level professors are immediately below academicians—the ceiling short of academicians.
I have always done TCM research, and I have been studying clinical medicine (Western medicine) for less than a year. So although I already have rich experience in oncology and neurology—enough to judge whether a person should undergo prophylactic cancer removal surgery—my authority is still hard to compare with that of a second-level professor.
Complete removal of the pancreas is no small matter, which is why my uncle’s family hesitated before the operation. In fact, their family is a medical dynasty: my uncle himself and his wife are both chief physicians (already a senior professional title in the medical system). In addition, nearly ten of their close relatives are doctors in hospitals with fairly high titles. Their connections within the medical profession are therefore very broad.
That such a family, when told by a second-level professor that one of their members had a highly suspected risk of malignant pancreatic cancer, was still at a loss and flustered—this shows how helpless ordinary people must be when facing a similar situation. Last Thursday, my uncle called me and asked me to take this niece to PUMCH over the weekend to see the hospital’s pancreatic expert, and asked me to make the decision on his behalf.
The medical profession has long had the saying “a doctor does not treat his own family.” When a close family member faces a major illness, it is quite normal for a doctor to dare not make major decisions or participate in treatment. Medical decisions need to be free of emotional influence in order to make the most rational choice, which close relatives usually cannot do.
My uncle trusts me completely—both my character and my professional level—so when he, as a father, could not make this major decision for his daughter, it is understandable that he hoped I would help. Entrusted in this way, I certainly did not dare to take it lightly.
After reviewing this cousin’s records, I immediately judged that the second-level professor’s advice was nonsense, highly unprofessional, and utterly disproportionate to his status. The pancreas is one of the most important organs of the digestive system; complete pancreatectomy greatly affects the patient’s remaining life. This cousin merely has chronic pancreatitis, and the probability of malignant transformation of chronic pancreatitis is actually very low—not the high risk the second-level professor claimed.
From her imaging findings, I judged that she could not possibly have cancer at this stage. I have reviewed the examination reports of no fewer than 10,000 cancer patients and am very familiar with cancer imaging. Such regular calcifications and fibrotic lesions are distinctly different from cancerous tissue; even junior Western clinicians should be able to tell.
I also looked up the incidence of pancreatic cancer in China: 3.5 per 100,000, which is very low. Among chronic pancreatitis cases, even hereditary chronic pancreatitis—the type most likely to become cancerous—has an incidence only 10–20 times that of normal people; non-hereditary chronic pancreatitis is only about 4 times that of normal people.
Using simple math, one can calculate the probability of malignant transformation in chronic pancreatitis patients; the probability is at most 7 per 10,000. To have a person’s pancreas removed for a 7-per-10,000 event is simply absurd—and the person proposing this was actually a second-level professor specializing in pancreatic disease.
His other basis was the patient’s elevated CA19-9. But this marker is not specific to cancer; it is one of the common markers of chronic pancreatitis. Doctors in other fields not knowing this is understandable—different fields are separated by mountains. But for a second-level professor in the pancreatic field to readily conclude that the patient’s pancreas had a high probability of cancerous change, without more careful continued monitoring and evaluation, and to directly demand pancreatectomy—that is reckless.
After reviewing the records, the PUMCH expert reached a judgment almost identical to mine. First, he agreed that this could not be cancerous tissue; second, he also pointed out that the probability of chronic pancreatitis progressing to pancreatic cancer is very low, and that removing the pancreas to prevent pancreatic cancer was strange; third, he felt that the disadvantages of pancreatectomy were too great and there was absolutely no need to rush to remove the pancreas; instead, the patient could be monitored and evaluated more cautiously, and once malignancy was excluded, regular follow-up observation would suffice.
So he ordered some tests. A repeat CA19-9 was done that day, and the result soon came back: the marker had dropped sharply to near the normal range. This is a typical pathological phenomenon of chronic pancreatitis. His opinion and the repeat result finally lifted the weight off my uncle’s family’s minds, and I could return to school Sunday afternoon with peace of mind.
Why do I tell this story in such detail? Because I often encounter similar situations: patients with precancerous lesions consult me about whether they should have surgery in advance to remove tissue or organs that might become cancerous. Such questions rarely have a simple, uniform answer; they require individualized analysis based on the patient’s specific situation.
But some general principles apply to every patient. Prophylactic cancer removal must be approached with great caution; one cannot simply remove related tissues and organs whenever someone has a disease that counts as a precancerous lesion. If that were the case, half of our country’s population would have their stomachs removed, because the H. pylori infection rate in China is nearly half, and H. pylori infection is one of the precancerous lesions of gastric cancer. China also has more than 100 million hepatitis B virus carriers or hepatitis B patients, and hepatitis B is a precancerous lesion of liver cancer. The cancerous transformation rates of H. pylori positivity and hepatitis B are both close to that of chronic pancreatitis.
Should all these people have their stomachs or livers removed in advance? The answer is of course no. Repeatedly cutting out tissues and organs is an extremely reckless and irresponsible act. Some doctors who overstepped on this issue—such as Liu Xiangfeng of Xiangya Hospital—have already been sentenced to prison. Before sentencing, he was also a big name in his department!
Only when the risk of malignant transformation is extremely high—for example, the 100% cancer rate of familial adenomatous polyposis, or the 10%–30% cancer rate of pulmonary atypical adenomatous hyperplasia—do these count as high-risk precancerous lesions. If, combined with other indicators, the likelihood of future cancerous change is judged to be high, then local prophylactic excision of the lesion can be considered. In addition, for some potentially cancerous tissues on the skin, the surgical scope and side effects are small, so the threshold for choosing excision can be somewhat relaxed. But lesions in important organs with a low probability of malignant transformation should never lightly lead to organ removal.
After this experience, my wife and I reflected: when a medical dynasty like my uncle’s family panics in the face of such a problem, ordinary families will be even more at a loss after hearing a second-level professor’s advice. After all, each Class-A tertiary hospital has only a handful of second-level professors, and they are only one step away from academicians! Who would dare not believe what they say?
We also felt a lingering fear, because our own family members may similarly encounter such problems, and before such medical authority they may have no choice but to obey. This also sounded a warning bell for me: I am now studying clinical medicine full-time; after graduation and a series of exams, I will simultaneously hold prescribing rights in both TCM and Western medicine, and may face large numbers of patients in the future. If I do not carefully evaluate each patient’s condition, I too will make such mistakes—and these mistakes will threaten the lives and health of many people. That would be bad not only for patients but also for myself.
I am grateful that the PUMCH expert’s judgment was almost identical to mine. Without his timely correction, it would have been hard for me alone to dispel the shadow over my uncle’s family. Even with my very professional analysis, they would still have found it hard to fully let go, and would probably have lived in fear thereafter.
Last week, my own sister, father, and wife all developed health problems one after another, and combined with the problem of my uncle’s child, it all landed on me for advice. For a whole week, between classes, I had to devote myself fully to these relatives’ health issues. When I returned to school on the weekend, I felt completely exhausted and fell asleep quickly on the train.
Fortunately, the final outcomes were all satisfactory, with no high-risk surprises. Had I not studied Chinese and Western medicine for so many years, and had I not been a calm person by temperament, I doubt I could have coped. This shows that one really cannot be too ignorant of medicine.