How do people die from cancer?

Ranjana Srivastava in The Guardian

Our consultation is nearly finished 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 I’m 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, it’s 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 first 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 fighting,” 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. “I’m afraid you’re dying,” I began, as I held her hand. But just then, her husband marched in and having heard the exchange, was furious that I’d 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.

It’s 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 decisions, plan their affairs 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, it’s understandably even more difficult to tread close to the issue of just how one might die.

Thanks to advances in medicine, many cancer patients don’t die and the figures keep improving. Two thirds of patients diagnosed with cancer in the rich world today will survive five years and those who reach the five-year mark will improve their odds for the next five, and so on. But cancer is really many different diseases that behave in very different 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 indefinitely. This is why I think it’s important for anyone who wants to know, how cancer patients actually die.

‘Cancer cells release a plethora of chemicals that inhibit appetite and affect the digestion and absorption of food’ Photograph: Phanie / Alamy/Alamy

“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 body’s usual defences to spread, or metastasise, to other parts. When cancer affects a vital organ, its function is impaired and the impairment can result in death. The liver and kidneys eliminate toxins and maintain normal physiology – they’re normally organs of great reserve so when they fail, death is imminent.

Cancer cells release a plethora of chemicals that inhibit appetite and affect the digestion and absorption of food, leading to progressive weight loss and hence, profound weakness. Dehydration is not uncommon, due to distaste for fluids 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 – it’s important to understand that the lungs (or other organs) don’t stop working altogether, but performing under great stress exhausts them. It’s like constantly pushing uphill against a heavy weight.

Cancer patients can also die from uncontrolled infection that overwhelms the body’s 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 or infiltration 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 difficult, 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 influence in a few ways – by causing seizures, paralysis, bleeding or behavioural disturbance. Patients affected 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 effect” 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 suffering and that they typically don’t shorten an already limited life.

It’s 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 effective 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 find yourself living in an area where a formal service doesn’t 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 difficult, but you should expect an estimation in terms of weeks, months, or years. When it comes to asking the most difficult questions, don’t expect the oncologist to read between the lines. It’s your life and your death: you are entitled to an honest opinion, ongoing conversation and compassionate care which, by 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, it’s worth reminding ourselves of the part we can play in ensuring a death that is peaceful.

Cricket is losing the popularity contest

George Dobell in Cricinfo


The absence of any cricketers from the BBC's annual awards bash is another stark warning of the invisibility of the sport in the British mainstream


Stuart Broad and Joe Root played key roles in the Ashes win, but neither man made the BBC Sports Personality shortlist © Getty Images



There are some things - good teeth, a parachute, a car that starts in wet weather - that you appreciate more in their absence.

So it was when the contenders were announced for the BBC's Sports Personality of the Year award. In a year when England have won the Ashes, when Joe Root has been rated - albeit briefly - the best Test batsman in the world and when Stuart Broad has bowled out Australia in a session, there was no room for a cricketer in the 12-strong list.

That is not to denigrate the merits of each contender or accept the somewhat self-congratulatory worth of the award. But there was a time when Ashes success warranted open-top bus rides through Trafalgar Square and MBEs all round. There was a time when cricket seemed to matter more.

But that was when cricket was broadcast on free-to-air television. And, whatever the many merits of Sky's coverage of England cricket over the last decade or so, it is hard to avoid the conclusion that the game, starved of the oxygen of publicity in the UK, is diminishing in relevance by the year.

The broadcast deal is not cricket's only issue. Many school playing fields are long gone and cricket, with its demand for time and facilities, cannot reasonably be expected to fit into many teachers' timetables. The world has changed and a game that lasts either a full afternoon or five days may have lost its appeal to a quicker, more impatient world.

When Warwickshire first won the County Championship, a huge crowd greeted their return to New Street Station; if they win it next year, the local paper will pick up a short report paid for by the ECB and find a column inside the paper for it. The warning signs are everywhere.

Which is why T20 cricket - and televised free-to-air T20 cricket - is so vital. It is the vehicle by which the game can reconnect and inspire another generation of players and supporters. The hugely encouraging spectator numbers in 2015, spectator numbers that owe a great deal to the marketing nous of some counties, shows there is hope and potential. It remains a great game. We just need to expose more people to it.

It seems the penny has dropped. While nothing is yet resolved, it does seem that some key figures at the ECB have accepted the counties' argument that free-to-air coverage - either on television or on-line - has a part to play in the next television deal.

They had hoped that a new, city-based T20 league would enable them to squeeze enough money out of the next broadcast deal to make the problem go away for a while. But the counties saw, to their credit, that this would have been a short-term solution. They saw that all the redeveloped stadiums in the land and a bank account boasting reserves of £80m or more (as the ECB have) was no use if those stadiums were rarely full.

They saw, unlike the previous regime at the ECB, that money does not make everything alright. That not everything of value can be packaged and sold. That they exist to nurture and develop the sport and the money they make is a valuable tool to that end, not the end in itself.

Cricket Australia have already journeyed that way. They took a hit on the Big Bash broadcasting deal, realising that it was more important for the sport to reach a mass audience on free-to-air TV rather than earn short-term riches on a subscription panel. They have pointed the way for the ECB.

It currently seems likely (it could change) that, between 2017 and 2019 at least, the English domestic T20 tournament will be played in two divisions with broadcasters focussing almost exclusively on the top division. Many of the counties hope that format will remain long after the new broadcast deals begin in 2020; some at Lord's hope it will be a Trojan horse for an eight- or nine-team event. If that latter argument wins in an era of subscription-only coverage, the game will become invisible across vast tracts of the country. It will retract yet further.

That would be a missed opportunity. For there is, right now, much to like about English cricket. While football - with its spoilt-brat millionaire heroes - has lost touch with the man in the street, cricketers have re-engaged. They play with a smile, they stop for autographs and photos. They remind us that it is perfectly possible to be hugely talented, successful and likeable.

The national team play exciting, joyful cricket. They have, in Jos Buttler, a man who can produce the sort of innings we used to see only when the finest Caribbean cricketers played the county game. They have, in Ben Stokes, an allrounder to make football-loving kids want to pick up a bat and ball; a man in Joe Root who might be the finest batsman in the world; a leader in Charlotte Edwards who has remained at the top of her sport throughout her career and done a great deal to further her sport. And, at a time when a few shrill voices would have us believe that communities of different faiths and cultures cannot coexist, a man in Moeen Aliwho gently shows us otherwise. There is much to celebrate in cricket.

But who will know unless they have a cricket-loving parent, they attend a private school or they come from an Asian community where the game remains relevant? How will the sport reach a new audience? How, in the long-term, will the value of the broadcast deals be maintained if the market diminishes? Cricket in England has become a niche and the absence of a cricketer in the Sports Personality of the Year list is another sign.

The money earned over the last few years has enabled the ECB to do many admirable things. They have led the way in the funding of disability cricket, the development of women's cricket and the improvement of facilities from the grassroots to the international game. All of this would have been desperately difficult without Sky's investment.

Nor is the past is not quite as marvellous as is remembered. Channel 4's coverage of two Ashes series - now talked about as if it were a golden age - was interrupted, in all, by 33 hours' worth of horse racing. Channel 4 also persuaded the ECB to start Tests at 10.30am one summer in order not to disrupt the evening scheduling of The Simpsons and Hollyoaks.

Equally, the BBC coverage of "Botham's Ashes" of 1981 was interrupted by programmes such as Playschool, Chock-a-block and The Skill of Lip-Reading while, for several years, their Sunday League coverage consisted of a single camera. Still, for many of us, it was our gateway drug to this great game. And yes, it seems to fair to reflect whether the BBC, for all the excellence of its radio coverage, for all its good intentions and the fine things it stands for, is currently keeping its side of the bargain when it comes to broadcasting sport.

Since 2006, Sky, with their multiple cameras, has taken cricket coverage to a new level. By broadcasting all England games home and away - something of which we could not dream 25 years ago - guaranteeing weeks of county coverage each season, and their willingness (a willingness we often take for granted in the UK but which is rare elsewhere) to ask the hard questions in interviews and commentary, they probably offer the best service cricket lovers have ever had.

Or at least those who can afford it. And there is the rub, because whatever the virtue of the Sky deal for the ECB's finances and whatever the virtues of their coverage, the fact is that vast sections of the country have no access to live cricket on television. In a nation where an uncomfortable number have the need of foodbanks, it is grotesque to think most could afford subscription TV if they only cared enough.

And whatever the benefits of sending coaches into primary schools - and Sky's money has helped fund Chance to Shine - it is hard to believe that 1,000 hours of helping kids hit tennis balls off cones will ever replace one hour of inspiration provided by watching the likes of Ian Botham, Andrew Flintoff or Ben Stokes lead England to the Ashes. Nothing can replace the oxygen of publicity. The benefits of the Sky money have long since been counteracted by the negatives in the reduced audience.

The water has been rising round our feet for some time. We have seen reports of falling participation numbers, we have seen England teams disproportionately reliant upon cricketers who learned the game either abroad or in public schools, and we have seen newspapers that used to take pride in their county cricket coverage abandon it almost completely. We have seen poorly attended international games - only the Ashes seems to be immune from the decline -  The absence of a cricketer from the Sport's Personality of the Year list - whatever the imperfections of that contest - is the latest symbol of the decline. We're fools to ignore it.

This is not meant to sound pessimistic. Were there a fire in the building, one could remain optimistic of escape while still sounding the alarm. We have a great game to offer. But, as Bob Dylan put it, let us not talk falsely now, for the hour is getting late.

Artificially prolonged old age is the new iatrogenic malady. - When it's time to go, let me go, with a nice glass of whisky and a pleasing pill

Advances in science are keeping us alive for longer and longer, but we are denied the right to die with dignity. It is grotesque

• 
• • Margaret Drabble
  • The Guardian, Thursday 2 January 2014

'Don't blame us if we are cluttering up the system. What we want and need is simple: a change in the law concerning assisted dying and voluntary euthanasia.' Illustration: Matt Kenyon

Back in the mid-70s, we were introduced to the notion of "medical nemesis" by the Austrian philosopher Ivan Illich. He warned us that doctors may do more harm than good, and that some diseases (which he labelled iatrogenic) were caused, not cured, by medical interventions. This doctrine has been widely accepted – we all know about the dangers of overprescribing antibiotics, about the risks of over-zealous or misinterpreted scans, about the creeping medicalisation of childbirth – but its application to old age and death is what interests me here. One of Illich's arguments in those days was that medicine, despite its apparent successes, was not notably increasing life expectancy. Alas, he was wrong. Artificially prolonged old age is the new iatrogenic malady.

We can't switch on the news without being told we will live longer, work longer, and survive on diminishing pensions or overpriced annuities. Newspaper columnists tell us we are selfish and that the young are suffering from our claiming an unfair share of state support. They begrudge us our bus passes, one of the few well-earned consolations of age. As we move into our unwanted last decade, we will, entirely predictably, become lonelier and lonelier and more and more likely to suffer from dementia and more and more expensive to maintain.

It would be unfair to blame doctors or health professionals for our longevity, which may be attributed to causes other than surgical ingenuity and pharmacological innovations and deadly life support machines, but it is not surprising that many of us feel gravely disappointed by the help and relief on offer to us at the end of life.

We look in vain for compassion, dignity, even common sense. We look in vain, despite what we are told, for adequate pain relief. Medical professionals seem far more interested in keeping alive barely viable premature "miracle" babies with a poor long-term prognosis than in offering reassurance to the growing and ageing multitudes who long to depart peacefully. They keep the babies alive because it's challenging, and very few people dare argue that it's not a good thing to do. They keep us alive because they are forbidden to give us what we want and need, and they are too frightened to question the law. There's something wrong there.

Don't blame us if we are cluttering up the system. What we want and need is simple. We want a change in the law concerning assisted dying and voluntary euthanasia, and help, if need be, to die with dignity.

The groundswell of opinion in favour of change is unmistakable. How often do you hear phrases like "you wouldn't let your dog suffer like that"? Three-quarters of the population backed Lord Falconer's assisted dying bill on its first reading in parliament. The bill would allow people who are terminally ill to receive the help they need to die, if that is what they choose. But can we have what we want? No. The politicians won't let us, the bishops won't let us, the health professionals aren't allowed to let us. It's grotesque.

Those suffering from incurable diseases need to be able to choose without penalty the help which they are at the moment denied. The elderly need to be able to plan ahead clearly, and to make their own choices about when their lives are no longer worth living. There seems to be some conspiracy to stop us thinking about the end game we all shall play. So we shuffle on, until it's too late to make any decisions at all, and we become helpless pawns in the politics of deferral, and utterly dependent on the humiliating procedures that for all our rational life we so wished to avoid.

It is my hope that in my lifetime the law will change, taking with it the fears that add so much terror to death. How wonderful it would be, if we knew that we would not be obliged to contemplate the bodily and mental decay that threatens us all. That we could opt out, and make our quietus, not with a bare bodkin or a plastic bag, or by jumping off the top of a multistorey car park, but with a nice glass of whisky and a pleasing pill – and so good night. How the heart would lift with joy at the good news. I don't go for Martin Amis's suicide booths, but I'm with Will Self all the way about the right to die when and how we want. When it's time to go, let's just go.

At the moment, it's not that easy. My husband, Michael Holroyd, fondly believes that as the longest serving patron of the Dignity in Dying campaigning organisation, he will be allowed to die in peace, but no, the doctors, in mortal fear of parliament, the law, the press and the General Medical Council, will be slavishly working to rule and obeying orders and striving officiously to keep him alive as they observe their archaic Hippocratic oath. It will be just like it was in the old days, when Simone de Beauvoir described her mother's death, in the ironically titled A Very Easy Death. If a woman of her intellect and clout couldn't prevent her mother from being hacked about by surgeons on her deathbed, what hope have we?

The best new year's gift an ageing population could receive is the right to die. As the philosopher Joseph Raz argues "The right to life protects people from the time and manner of their death being determined by others, and the right to euthanasia grants each person the power to choose themselves that time and manner." The right to die is the right to live.