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Volume 10, Number 2


Everyone's Guide to Cancer Therapy
How Cancer is Diagnosed, Treated, and Managed Day to Day

Malin Dollinger
Ernest H. Rosenbaum
Greg Cable
Adapted by the Canadian Medical Association
Richard Hasselback, Editor

Somerville House Publishing, Toronto, 1992; 636 pp; $35.24 (hardcover, CMA members), ISBN 0-921051-58-1; $24.54 (paperback, CMA members), ISBN 0-921051-59-X

Cancer is a distressing and bewildering disease. This book is intended as a problem-solving and information guide for patients and their families and friends, from the earliest detection of cancer to palliative care. Although originally written by authors from the United States, it has been adapted for Canadian use by Canadian cancer specialists. Some chapters have been revised extensively because of major differences in treatment philosophy, whereas others have undergone only minor changes. The result is a text that represents the mainstream of therapeutic oncology in Canada.

The text is organized into four sections: diagnosis and treatment; supportive care; developments in assessment, diagnosis and treatment; treatment of the common cancers. The first chapter succinctly covers the biologic aspects of cancer, the cancer referral system, decision making, the team approach and therapeutic options (surgery, radiation, chemotherapy, biologic therapy and unproven therapy). Most topics are purely factual but others provide advice such as how to facilitate communication and when to ask for a second opinion.

The section on supportive care is potentially the most valuable for the reader. It contains extensive advice on minimizing the adverse effects of cancer therapy and pain due to cancer. It also emphasizes the rehabilitative approach, with chapters on physical fitness, sexuality, living with an ostomy, use of relaxation techniques and coping with negative emotions. These topics are poorly dealt with by most physicians, yet they are important for patient well-being.

In the last section, 46 mini-chapters are devoted to specific types of malignancy. They cover investigations, treatment according to the stage of disease and prognosis. This encyclopedic approach means that the individual chapters are brief, but at least 10 pages each are devoted to the chapters on breast, lung, colorectal and prostate cancer and even to rare tumours such as carcinoma of the penis and ovarian germ-cell tumours. Readers will appreciate the many diagrams used to show the location of the affected organ and the surrounding structures. The rapid pace of developments in biologic therapy may change some of the recommended approaches within the next 5 years, but most of this material will remain valid. Given the low cost of this text, it is reasonable to contemplate replacement with an updated version within a few years.

I have a few criticisms of this comprehensive approach. It leaves no room for a discussion of the potential adverse effects of each treatment, but this information should be readily available from the oncologist. The terminology in the basic science sections (e.g., "random mutating agent, immunosuppression") may be intimidating to those with less-than-average reading skills. However, the text has an extensive glossary. The only glaring inaccuracy I noted is the overly optimistic statement that adjuvant chemotherapy cures almost one half of premenopausal patients with breast cancer who would otherwise have a recurrence.

This book can be recommended without reservation to patients (or other lay persons) who desire an in-depth knowledge of cancer biology, cancer treatment and suggestions for maximizing the quality of life. Although the treatment sections will be too basic for the specialist in oncology, they will serve physicians and nurses, because it delves into many subjects that are poorly taught in training programs.

David Warr, MD, FRCPC
The Princess Margaret Hospital
500 Sherbourne St.
Toronto, ON, M4X 1K9

No Longer Patient
Feminist Ethics and Health Care

Susan Sherwin

Temple University Press, Philadelphia, 1992; 286 pp; $39.95 (US); ISBN 0-87722-889-2

Dr. Susan Sherwin of the Department of Philosophy at Dalhousie University, Halifax, has an interest in the development of a feminist health care ethic in the hope that this perspective will improve our approach to policy and clinical questions in medicine.

This book defines the many theoretic positions from which feminism can be derived and places the author's views among them. Central to her Zeitgeist is the division of society into oppressors and victims. Sherwin views oppression as ubiquitous, though often invisible, but nevertheless amenable to change. She is an optimist in that she considers social history and evolutionary biology to be man-made phenomena, which can be ameliorated by the application of appropriate democratic principles. Her bias is to impose these principles because they appear just. For instance, she observes that for the most part policy and health care decisions are made by white, middle-class men (administrators and physicians), whereas the vast majority of health care workers (allied health care professionals, domestic hospital staff, technicians, office staff) are mostly women. These women are sometimes economically disadvantaged, physically disabled, Native Canadians, African Canadians, recent immigrants or otherwise marginalized individuals and as such have no voice in decision-making. She believes that this large group reflects the larger community of potential patients and that its input more closely represents true health care need than do the opinions of the professional elite (marred as these are by self-interest and the wish to preserve the hierarchy of power). She would like to impose egalitarian decision-making bodies on the health care system.

Essentially optimistic, (she sees human nature as malleable) Sherwin divides the world into oppressors (with bad motives, even if subconscious) and oppressed (those who would, if given the opportunity, convert the world into a better place, at least with respect to health care). She recognizes the existence of oppressive acts committed by the oppressed (e.g., white female nurses discriminating against women of colour in allied disciplines), but she attributes this to the oppressive social system in which we live rather than to something more fundamental, and unalterable, such as the instinct for survival which, in certain situations, makes monsters of us all.

From my viewpoint the book is na´ve. The evidence is derived from literature that is one-sided, based on personal observation, selective statistics, subjective opinions and hasty conclusions. The author does not cite results from more objective studies of the various areas discussed, such as abortion, reproductive technologies, diagnosis, sexuality and beneficence or autonomy. Probably this is because the author sees objective, hypothesis-driven research as largely mechanistic and irrelevant, a restrictive imposition on our intellect that is created by the scientific elite for morally questionable purposes. She favours personal observation and the reporting of personal experience. She believes, rightly, that this approach encourages the active participation of the subject in research and preserves, in the form of reportable data, elements that are hard to measure (i.e., emotional reactions and individual variation). Unfortunately for the reader looking for universal truths, excerpts from individual experience and opinion, while informative and valuable, do not always persuade.

However, this controversial book is well worth reading. Ideally it should be read alongside other current books on the ethics of health care, for instance, Molloy's Vital Choices: Life, Death and the Health Care Crisis (Viking Press, Toronto, 1993), in order to compare and evaluate the many perspectives that inform and complicate bioethical decision-making.

Mary V. Seeman, MD
Clarke Institute of Psychiatry
250 College St.
Toronto, ON, M5T 1R8

Nobody Nowhere
The Extraordinary Autobiography of an Autistic

Donna Williams

Bantam, Toronto, 1992; 219 pp; $12.95 (paperback); ISBN 0385-254-253

This is a story of two battles, a battle to keep out "the world" and a battle to join it. It tells of the battles within my own world and battle lines, tactics used, and casualties of my private war against others. This is my attempt at a truce, the conditions of which are on my terms. I have, throughout my private war, been a she, a you, a Donna, a me, and finally, an I. All of us will tell it like it was and like it is. If you sense distance, you're not mistaken; it's real. Welcome to my world.

So begins the extraordinary book, Nobody Nowhere. Donna was different from the beginning. Her earliest memories include a vivid awareness of her own self-contained world and an awareness of the outside world experienced as though under glass. Over and over, the glass would be shattered as the world tried to make contact with a child lost in spots of colour.

Not able to relate to the real people" in her life, Donna invented friends to people her world and to keep the world from hurting her. From the age of three, an angry and abrasive "Willie" defended her against night and daytime terrors. When she was six, a chance encounter in the park gave Donna a fleeting glimpse of another way of life, and her second character was born: in the belief that she could join the world and be normal, Donna took on the pleasing and compliant persona of "Carol." As she continued the push-pull with the world, she, Donna Williams, became increasingly invisible to herself and increasingly incapable of feeling.

As the story unfolds, we see the almost insurmountable odds that this young woman faced just to survive. Donna suffered alternate abuse and neglect at the hands of an extremely troubled family. Failed by the educational system, subject to gross cruelty and "domestic prostitution" in relationships with men, and suffering from vitamin deficiencies that aggravated suicidal depressions, Donna Williams soldiered on, sometimes relying on abrasiveness, sometimes on passivity, often putting up with the most awful conditions just to get by. Underlying everything else was her autism, a disability that forced her to only guess what "normal" might be. It is truly amazing that this young woman not only survived, but also managed to leave destructive relationships, seek help for her depression, and sustain a therapeutic relationship (including a misdiagnosis of schizophrenia) long enough to achieve a university education and unlock the mystery of who she is.

When Peter Gzowski interviewed Donna Williams on his radio program Morning-side, it was evident that writing this book has not "fixed" her. Her world is clearly different from the world that most of us inhabit. Her acute sensitivity to sensation (especially to colour and light), the difficulty she often has to make sense of the words spoken to her, and her difficulty in forming personal relationships have often kept her (and presumably keep other autistic people) from understanding the world as the rest of us experience it.

Donna Williams' autobiography addresses the problem of communication from the perspective of a person with autism. For Donna, the discovery of a medical definition of her condition gave her a tool with which to make sense of who she is. Writing Nobody Nowhere as an exercise to see "what kind of mad I am" has served as a self-validation. Her writing clearly communicates that behind what often must have seemed bizarre behaviour, was not just a "blonk" but, rather, a real person -someone who wanted to belong but did not know how. As she indicates in her introduction, she has been able to give up Willie and Carol and has joined the world as herself. Incidentally, she has given us a unique insight into the nature of autism.

Although Nobody Nowhere rings with an authority that no one on "the world's" side of the disease has previously been able to muster, we should not make the mistake of faulting the book for what it is not. It is not a comprehensive textbook on autism, nor does it deal with recent exciting breakthroughs in the treatment of autistic children. It is not down on parents, nor does it critique present methods of treatment. It is an outstanding book written by a highly intelligent, articulate, and extremely courageous woman; in facing incredible odds she has overcome much, and through her courage she has given much.

Welcome to "the world", Donna.
Carole Payne, MLS
151 Courcelette Rd.
Scarborough, ON, M1N 2T1

[Editors' note: The sequel to this book, Somebody Somewhere, has just been published.]