The Concept of Tenju-gann, or "Natural-End Cancer" T he concept of Tenju-gann proposed by Kitagawa et al. 1 and dis- cussed in the accompanying editorial by Kennedy 2 deserves broader application than these authors suggest.
Although cancer is increasingly an illness of the elderly, there remains a significant burden of disease among the young and middleaged, particularly in terms of years of potential life lost. There is also evidence that some solid tumors occurring in those younger than 40 years behave more aggressively and result in poorer outcomes than the same disease diagnosed at a more advanced age. 3,4 Being cheated of health and forced to pay the cancer "tax" before enjoying the fruits of a long life is a devastating situation that leads patients, families, and physicians to pursue every reasonable attempt at therapy. The vast majority of advanced solid cancers become refractory to therapy over time or never demonstrate initial sensitivity to systemic treatment. In many cases, symptomatic and supportive care become the best and most appropriate therapeutic options. In these situations, the concept of Tenju-gann or "natural-end cancer," as presented by Kitagawa et al. 3 could be applied to patients of all ages, including children, in an effort to help them and their families cope with the shattering consequences of terminal disease. The increasing focus on quality of life issues in clinical trial design as well as the development of hospice organizations are practical attempts at understanding and relieving the suffering of advanced malignancy. The concept of Tenjugann may further aid in our care of individuals with terminal disease, regardless of age. It could help avoid the application of medically futile therapeutic procedures that interfere with the ability of our patients to experience the "peaceful death with minimal suffering" that is central to the diagnosis of a Tenju-gann cancer. This does not imply therapeutic nihilism, but rather the admission that, for most patients diagnosed with advanced cancer, succumbing to their disease is inevitable and leads to a "natural-end" despite aggressive therapeutic efforts. Dying of advanced cancer at age 40 years is no less "natural" than dying of the same illness at age 90 years.
Oncologists can play a critical role in helping patients of any age accept their disease and experience a peaceful death. Perhaps there is a derivative of Tenju that could encompass those dying after having enjoyed shorter-than-expected lives. We should not let reverse ageism deprive our younger patients of the potential comfort that is the ultimate result of the application of the philosophy of Tenju-gann.
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