Cancer Investigation, 24:331–332, 2006ISSN: 0735-7907 print / 1532-4192 onlineCopyright c© Taylor & Francis Group, LLCDOI: 10.1080/07357900600633940

OP-ED

Why Did He Die?Damian A. Laber, M.D., F.A.C.P.

Department of Medicine, Division of Medical Oncology and Hematology, University of Louisville, J.G. Brown Cancer Center Louisville,Kentucky, USA

ABSTRACT

The true reason why cancer patients die is not absolutely clear. The decreasing rate of post-mortem examinations in this group of patients is discussed. Understanding how cancer cellskill people can elucidate therapeutic approaches that might benefit our patients. Finally, theauthor pledges to support research to understand the reason why many of our patients die.

To understand life we have to look at death.I was completing my paperwork when my nurse clinician

called: “Did you know about Mr. Smith? He died two days ago.”Unfortunately, this notice is not infrequent in the life of an on-cologist. But, why did he die? The majority of the time, “why”refers to the impossible to answer question about “why him orher,” because the medical explanation of dead is usually obvious.Is it?

Mr. Smith (not his real name) was a 62-year-old man, whopresented with anorexia, fatigue, and generalized weakness. Hewas diagnosed with metastatic prostate cancer and treated withandrogen ablation. His symptoms improved and the prostatespecific antigen (PSA) level declined significantly. Four weekslater, he died.

Most of the patients with carcinoma of the prostate are el-derly and live with the disease for years before succumbing ofor with it. At presentation, the tumor usually is sensitive to andro-gens and striking subjective or objective responses to castrationoccur (1). After hormonal therapy, reduction in PSA level usu-ally correlates with a positive response (2). Yet, the experiencedclinician cannot rely solely on that test. PSA expression itself isunder hormonal control. Therefore, sometimes, androgen depri-vation therapy can decrease the serum level of PSA independentof tumor response (3). Another exception is when PSA level

Keywords: Autopsy, Death, Prostatic neoplasms.Correspondence to:Damian A. Laber, M.D., F.A.C.P.J.G. Brown Cancer Center529 South Jackson Street, # 229Louisville, KY 40202e-mail damianla@ulh.org

does not match disease burden like with undifferentiated smallcell tumor (4). But that is not what happened to Mr. Smith. So,again, why did he die?

The true reason why cancer patients die is not absolutelyclear. Unfortunately, autopsies are seldom being performed inpatients with cancer. In Finland, investigators reported the mor-tality from various diseases, including the malignant neoplasmsof the genitourinary system, from 1955 to 1973 (5). The au-topsy rate of the deaths due to genitourinary neoplasms (27.4percent) was less than the rate recorded for all natural deaths(33.2 percent) in Finland. Many types of malignant urogenitalneoplasms remained significantly under-autopsied. These rateswere considerably less than the mean national autopsy rate of alldeaths which was 38.2 percent (5). A MEDLINE search look-ing for autopsy studies trying to clarify the true cause of deathin cancer patients revealed nothing for more than the last twodecades.

Complications of progressive cancer are usually easy to rec-ognize and are rightfully blamed as the reason for the demiseof many patients. A question that physicians sometimes face is,like in this case, what happened to a patient who was clearlyresponding to the treatment, and had no evidence of any majorcomplications from the cancer; like infections, coagulopathy, orinvolvement of vital organs?

Since the origins of medicine, postmortem examination hasprovided extremely valuable information about the human body.This powerful tool is being used by researchers to obtain tissuesamples (6) or determine the correlation with clinical findings(7), but not to find the ultimate cause of death. Trying to avoiddistress to surviving family members, many health professionalswho pronounce the death of a cancer patient do not requestpermission for an autopsy. I have found this concern to be farfrom the truth. Usually, people wish doctors to obtain as muchinformation as possible to help future patients.

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Understanding how cancer cells kill people can elucidatetherapeutic approaches that might benefit our patients. Shouldwe as physicians and scientists work a little harder at explainingthis to the people that have just lost a close loved one? I believeso. One of the main reasons cancer patients agree to participatein clinical trials is to gain knowledge about the disease, eventhough the information may not help themselves but other peo-ple. We can give them the chance to fulfill this unselfish goaleven after death.

The reason why a cancer patient dies is not always obvious.Research about this may help us understand more about malig-nancies and hopefully prevent the utmost feared complication—death.

REFERENCES1. Garnick, M.B. Prostate cancer: screening, diagnosis, and manage-

ment. Ann. Intern. Med. 1993, 118, 804–818.

2. Matzkin, H.; Eber, P.; Todd, B.; van der Zwaag, R.; Soloway, M.S.Prognostic significance of changes in prostate-specific markers af-ter endocrine treatment of stage D2 prostatic cancer. Cancer 1992,70, 2302–2309.

3. Ruckle, H.C.; Klee, G.G.; Oesterling, J.E. Prostate-specific antigen:concepts for staging prostate cancer and monitoring response totherapy. Mayo Clin. Proc. 1994, 69, 69–79.

4. Amato, R.J.; Logothetis, C.J.; Hallinan, R.; Ro, J.Y.; Sella, A.;Dexeus, F.H. Chemotherapy for small cell carcinoma of prostaticorigin. J. Urol. 1992, 147, 935–937.

5. Ahonen, A.; Penttila, A. Mortality and autopsy rate from urogenitaldiseases in Finland in 1955–1973. Scand. J. Urol. Nephrol. 1980,14, 91–99.

6. Roudier, M.P.; True, L.D.; Higano, C.S.; Vesselle, H.; Ellis, W.;et al. Phenotypic heterogeneity of end-stage prostate carcinomametastatic to bone. Hum. Pathol. 2003, 34, 646–653.

7. Roudier, M.P.; Vesselle, H.; True, L.D.; Higano, C.S.; Ott, S.M.; etal. Bone histology at autopsy and matched bone scintigraphy find-ings in patients with hormone refractory prostate cancer: the effectof bisphosphonate therapy on bone scintigraphy results. Clin. Exp.Metastasis 2003, 20, 171–180.

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