Dear Farrah

Dr. Ralph Moss has eloquently spoken on the politics of cancer in his open letter to Farrah Fawcett. I share his thoughts and especially appreciate his comments on how medicine in the US does not support involving the patient in their own care and actively obstructs any effort to choose other than the status quo.

On my own behalf, as well as that of my coworkers, and the readers of our weekly online newsletter, I want to wish you success in pursuing innovative cancer treatments in Germany. I applaud your courage in seeking an approach that hopefully will be less toxic and more effective than the treatments you have so far been offered in the US.

With this open letter, I also hope to counter some of the negative comments that have been made in the media about your treatment choices. Some of the derogatory comments about "the murky world of overseas clinics" have come from the tabloids - no surprise there. As your spokesperson told People magazine, "It is now clear that the tabloids are as invasive and malignant as cancer." I wish there were some way to shield you from their abusive attacks.

Far more surprising have been highly critical comments from individuals associated with major US cancer institutions. Isn't it ironic that before your diagnosis you served as a celebrity spokesperson for the American Cancer Society? Now, some people associated with ACS and similar organizations have forgotten this former service and, in effect, have washed their hands of you.

Interviewed by the Associated Press about your case, Barrie Cassileth, PhD, is quoted as saying, "I would [tell a patient considering alternative treatment] that they are signing their own death certificate. I would say they are wasting time they could otherwise spend happier and with their families." Dr. Cassileth is chief of the Integrative Medicine Department at the Memorial Sloan-Kettering Cancer Center, New York and has been prominently associated with your former organization, the ACS.

I find such statements both highly inappropriate and contradictory. Saying that people are "signing their own death certificate" by pursuing innovative cancer treatments outside the US implies that they would not be signing their death certificate had they only stayed in the US for treatment. While I do not presume to know the details of your case, I assume that you were fully informed by your American oncologists of the treatment options for your cancer, and found them unacceptable.

I am sure you did not make the decision to seek treatment in Germany on a whim, but after due deliberation of all your options. Dr. Cassileth's melodramatic statement implies that you are wasting your time by doing so and that you could instead spend "happier" time with your family. Not everyone will choose to, as it were, wait out the clock. I thoroughly understand your desire to seek more effective treatments, including those available abroad. This is of course a very personal choice, which is determined in part by one's resources and fighting spirit. But the fact that some people choose to seek out other possibilities abroad rather than give up hope at home is not a sign of irrationality.

Medicine develops unevenly and is still partly determined by national characteristics. (For confirmation, see Lynne Payer's classic Medicine and Culture.) Consequently, there are treatments available in Europe that are not yet available here, and vice versa. Dr. Cassileth seems to think that all German cancer clinics are a monolith and that all their techniques are the same and equally ineffective. But the topic of German innovative medical treatments is a huge one. According to one German Web site (www.klinik.de) there are presently 2,200 private clinics in Germany, containing 500,000 beds and treating 17.5 million patients annually. Many of these are cancer patients. These clinics were not set up to treat Americans, but primarily to serve the interests of the indigenous population. Germans in general (including many of their doctors) have a more positive attitude towards natural medicine than do their counterparts in America. In my experience, the German clinics are generally well run and are in full compliance with both local laws and international standards of ethical patient care.

Germany has long been a world leader in cancer research and treatment. German biologists pioneered almost every step in understanding the nature of this disease. Despite the terrible setbacks of World Wars I and II, German doctors continue to be well trained and well informed on all aspects of cancer care. In the use of complementary medicine they are without peer in the West. German doctors have either pioneered or expanded the use of mistletoe, enzymes, thymic peptides, immunotherapy, hyperthermia, and a host of other innovative techniques. These methods are sometimes employed alongside surgery, radiation and chemotherapy, when these are deemed necessary.

A glance at this year's program of the 41st Medizinische Woche (Medicine Week), held October 27-November 1, in Baden-Baden, reveals a panoply of treatment options that are unknown by most American oncologists. Recently I had the honor of co-editing a medical textbook on the German approach to integrative cancer therapy with Josef Beuth, MD, professor of complementary medicine at the University of Cologne. Our volume, Complementary Oncology (Thieme) gives some idea of the range of these treatments and the depth of their scientific evaluation including, in some instances, through the use of randomized controlled trials.

In conclusion, Ms Fawcett, I hardly think you are wasting your time, much less signing your own death certificate, by going abroad for treatment. You have made a rational decision under extremely difficult circumstances, and that decision deserves the utmost respect, not a flippant dismissal of your survival prospects. All people of good will wish you the best of luck in your search for effective treatments.

References:Jefford M, Tattersall MH. Informing and involving cancer patients in their own care. Lancet Oncology 2002;3(10):629-37.