Over the past 10years, the prospects for the tens of thousands with the misfortune to be afflicted by the potentially crippling disorder of rheumatoid arthritis have improved dramatically.
The cardinal symptoms of swollen painful joints with the progressive destruction of bone and cartilage is serious enough, but the inflammatory process may also affect the functioning of the heart, lungs and blood vessels – resulting in a substantially increased risk of “all-cause mortality”, almost half as high again as it should be.
But over the past decade, between 2007 and 2014, that risk has fallen substantially, and is now only marginally higher than for the general population.
This astonishing, unprecedented improvement in life expectancy is obviously a marker that management of the illness has become vastly more effective.
How so? New, if very costly drugs have certainly been a contributory factor, but it is mainly attributable to a radical reevaluation of the “philosophy” of treatment, and what it might reasonably be expected to receive.
Most of the potent Disease Modifying Antirheumatic Drugs (or DMARDS) in current use were discovered half a century or more ago, and though they certainly alleviate the characteristic pain and swelling of the joints, they did not halt the disabling process of aggressive bone destruction that cause them to become progressively more misshapen. They were good but, frustratingly, not good enough.
Their tendency to cause side effects was a major limiting factor to their use, encouraging a policy of cautious prescribing, especially in the early stages of the illness when it may be relatively mild and confined to just a couple of joints in the hands. But perhaps, it was suggested, the goal of treatment should not merely be the control of symptoms, but rather stopping the inflammatory process in its tracks with the potent anti-cancer drug Methotrexate and steroids. The dose of Methotrexate would would then be progressively increased and further drugs added, to the point where they had effectively abolished all signs of inflammation. Further, it was argued, the sooner this was initiated, the better.
Initially, many specialists were reluctant, to adopt this radical approach in the early stages of the illness, for obvious reasons. As one put it: “The patient leaves the room and says ‘This doctor is completely nuts. I enter with pain in the wrist, only to be told I have to take this toxic cocktail of drugs.’”
However, it has been more than justified by the benefits in preventing that relentless bone destruction and, as noted, that dramatic improvement in survival. It is a most impressive achievement, with lessons for rethinking the management of other severe inflammatory disorders.
My recent observations in this column that “systematic surveillance” – regular scans and blood tests following surgery for localised tumours of the breast and colon – does not, it now appears, further improve the outcome has been criticised for being “discouraging and unhelpful”.
“I am left with the thought that the cancer will get me in the end,” writes a woman who has recently undergone surgery for early breast cancer, “and my optimism has somewhat waned.”
My apologies – but this is an, admittedly, understandable misinterpretation. Those who are cured by surgery – the vast majority – will obviously stay cured, and though many certainly welcome the reassurance of regular hospital check-ups confirming all is clear, they will, by definition, not materially alter the situation.
This necessity of ensuring that the routine surgical management of cancer, though apparently plausible, really makes a difference is further illustrated by a study reported in this month’s British Journal of Surgery into the merits of the radical procedure of excising all the lymph nodes in the neck in patients with cancer of the thyroid gland.
Surgery to remove the gland is itself highly effective, with a greater than 90 per cent cure rate. Does additional excision of the nodes in the neck in anticipation that the cancer might have spread locally improve on this? Apparently not – thus in future it is advised that those with the disease can be spared this traumatic surgical procedure.