Anticancer Surgical Intervention in Patients with Dementia, to Operate or Not to Operate? A Huge Ethical Dilemma

Abstract

A diagnosis of dementia could be frightening for those affected by the syndrome, their family members and caregivers. Dementia is the loss of cognitive functioning, which means the loss of the ability to think, remember, or reason, as well as behavioural abilities, to such an extent that it interferes with a person's daily life and activities. In fact, this is not a disease but a group of related syndromes. Dementia presents a neurodegenerative, progressively evolving, irreversible brain damage. Its symptomatology alters the patient's life in such a way that at the end he would be "another human being" with a blurred mind, doomed to die most probably by cachexia, lost in his new world. By 2050, one new case of dementias is expected to develop every 33 seconds, resulting in nearly 1 million new cases per year. Yet, other evil ailments could simultaneously appear to compose a more stressful condition. Unfortunately, the prevalence of cancer does not differ in the dementia population, and many face the agony of being treated surgically, non-invasively (chemotherapy, immunotherapy, radiation) or conservative (hormones, palliative medicine). It is to be expected that medicine should treat a person without dementia in just the same way it should treat a person with dementia. In reality, the actual situation of the affected (ability to sustain anaesthesia, live prognosis, quality of live, overall burden) should be strongly considered, alongside with the caregivers (how to cope, economics, psychology) [1][2][3][4].In the case of mild to moderate dementia, things are easier. The patient presents a significant degree of cooperation, while somehow express his opinion on the treatment and the caregivers carry a lighter load to cope. Meanwhile, life expectancy and quality of life are adequate for an interdisciplinary team (neurologist, psychiatrist, oncologist, surgeon, welfare worker, etc.) to suggest some kind of surgery. But in the case of moderate to severe dementia, especially in older individuals, a huge ethical dilemma rises among specialists and the family. To operate, or not to operate? Nevertheless, patients with mild to moderate dementia syndromes could experience postoperative cognitive decline with structural postoperative atrophy of the cortex and hippocampus, found in MRIs, mostly reversed after a time period, able though to stigmatize behavioural and cognitive qualities. Studies worldwide demonstrated that patients suffering from cancer with dementia are less likely to receive aggressive treatment (surgery, radiation) in their end of life than those who were not diagnosed with dementia. In some cases, chemotherapy combined with hormones treatment was suggested. This discrepancy raises important ethical questions for both the clinicians and the healthcare policy-makers. For example, is cancer screening necessary for patients with severe dementia syndromes? Should immunotherapy, adjuvant chemotherapy, or chemotherapy at all be administered? Should extensive surgical procedures and general anaesthesia be carried...