Cancer in the News

Two separate articles about cancer hit the news recently, both of which elicited a strong reaction. One was about the occurrence of certain types of cancer often being due to chance rather than environment or lifestyle, and the other about cancer being the “best” way to die.

Reactions to the first article range from “dangerous viewpoint” “irresponsible” “garbage in, garbage out” “nihilistic” “bad science” to “smoke away” “time to binge” “told you so”. The article was published by researchers at John Hopkins University in Science, a top-tier peer reviewed journal. Although that does not automatically mean that the study is correct, it does imply that the study has been reviewed and vetted by people a lot more knowledgeable than myself and the typical commenter. It is irresponsible to dismiss a study as “garbage in, garbage out” or “bad science” simply because the implications do not fit one’s worldview.

Speaking of implications, what exactly are they? The typical strawman conclusion is that a healthy lifestyle doesn’t matter. However, that is not at all what the study concluded. The study stated that about 1/3 of the cancers studied could be attributed to genes and environmental factors. It did not look at all cancers (notably breast and prostate cancers), nor at other medical conditions, such as diabetes, which are very much linked to lifestyle. Not everyone gets cancer (much less the subset studied), not all cancers are incurable, and not all deaths are due to cancer. The “dangerous viewpoint” seems to be a kneejerk reaction to an imagined conclusion, a simplistic caricature of what the study actually says. Even at face value, putting the many obvious benefits of a healthy lifestyle aside, isn’t it worth it to improve one’s chances, even if the potential is a fraction of 1/3?

Reactions to the second article seem even more extreme, and mostly negative. Dr. Smith uses Mr. Bunuel, a well-planned end-of-life cancer case, to argue that compared to the other ways of dying, cancer is preferable. It gives the patient an opportunity to reflect and wrap up. Dr. Smith did not say that cancer is good, or that dying is good, a concept many of the commenters seem to be unable to grasp; he did make a case that out of all the different ways to die, cancer is less bad than the others.

We all must face death, and not enough of us have thought about it as carefully as we should. It is an event that greatly affects many, something too important to ignore because of a visceral aversion.  It’s not like we’re getting out of this alive.

Let’s see if an analogy can help take the visceral reaction out of the equation. If one were to be downsized from a company, would it be preferable to be given a month’s notice so one could tie up loose ends and handover work in progress, to be fired on the spot and escorted to the door immediately, or to gradually have your salary cut and be abused by supervisors until you leave in disgust?

End-of-life is not so cut and dry. Cancers, treatments, and circumstances vary widely, and perspectives are very different. A doctor is trained to be detached out of professional necessity, and it seems to be this perspective that most of the commenters find offensive. The commenters seem unaware that Dr. Smith has likely seen more cancer deaths than them combined, and a view from that perspective is probably worth considering with one’s brain rather than dismissing with one’s gut. I largely agree with this first portion of his post – I would choose time and manageable pain over sudden death.

I cannot agree with the last sentence, however. He states, “…. and let’s stop wasting billions trying to cure cancer, potentially leaving us to die a much more horrible death”. Even in the context of his post, it is difficult to see how such a blanket statement could be considered reasonable. He specifically said not to waste money trying to “cure cancer” – not drugs with astronomical cost but merely extend suffering by a month or two, which would have been a more defendable position. Yes, a blog post is meant to be informal, but this is something that should have been taken out or properly qualified before hitting the “post” button.

How Long Would You Want to Live?

At birthdays, I’ve heard people wish others they live to 120. It’s a nice thing to say, since everyone wants to live a long life, no? Well, let’s see.

Other than the possible but statistically unlikely age of 120, let’s not make any unfounded assumptions about the rest of the world. That means, no anti-ageing miracle breakthrough, no cyborg-like mechanical integration, no brain-in-a-jar virtual reality, no special pleading.

Imagine Longoria, a 30 year old female born in a developed country, married with 2 kids, ages 1 and 4. According to the United Nations World Population Prospects, 2012 Revision, her life expectancy is around 80, and her children’s life expectancy is around 85 or so.

Cognitive Impact

Some say age-related cognitive decline starts in the 50s, while a more recent study shows that it starts in the 20s-30s. They all agree that cognitive decline accelerates towards the end. By 60 there usually is some objectively noticeable effects despite the self-delusion, and it is hard to imagine what an additional 60 years of decline will do after that. At 110 there is unlikely to be much of a mentally functioning “self” left, nor a veridical memory of it. And then come 10 long years to deteriorate. If Alzheimer’s/dementia sets in, which will for 1 in 5 reaching 80, the remaining decades would be more of a burden.  Unfortunately even if one does not have it by then, the risk of developing Alzheimer’s doubles every 5 years after 65 simply due to age.  It is hard to extrapolate to 120 due to low sample size, but the odds are not in one’s favor.  There is little joy in living to 120 if one cannot reasonably make sound decisions.

With the ability to learn, think, and remember diminished, it is likely that Longoria will spend decades behind the technology curve. Imagine an average 90 year old today in the digital, wireless, always connected world, marveling at how much the world has changed in a few short years, and how detached that must feel. Longoria will have 30 years of continued mental decline on top of 30 years of rapid technological advance, after she hits 90. Of course the premise is that keeping up with society in general is desirable. An alternative is to keep up with her peers rather than the larger general society; however this option is no longer available as all of Longoria’s peers would be dead for decades.

Physical Impact

The ageing process is brutal and unrelenting. Few if any machines can run for 100 years without major overhaul; similarly, virtually every piece of original equipment in the body will experience wear and tear, breakage and replacement. From vision, hearing, mobility, strength, endurance, to any other objective measure of health, Longoria will be on a steady decline.

Most seniors end up losing mobility and consequently their independence. For many, that happens around 85-90. Let’s give it the benefit of a doubt and say that happens to Longoria at 100. She will spend 20 long years using a walker, wheelchair, or in bed, needing assistance for even the most basic daily needs.

Social Impact

Undoubtedly, Longoria will outlive her spouse, her children, and her friends by decades. There is a very real possibility that she will outlive most of her grandchildren as well, and those grandchildren that have not died will likely be quite old and not in a position to be caregivers themselves.

All of Longoria’s old friends will have long died, and any new friends that still survive will be decades younger than her, and probably have a few generation gaps. It is unlikely that real, meaningful companionship will be attainable, especially with the cognitive decline. It is lonely at the top.

Financial Impact 

Most people plan for retirement and build their nest egg for 20-30 years at most. When the savings run dry, and obviously unlikely to generate new income, the situation becomes rather dire. Medical costs generally increase as people age, and senior care is not cheap. Most likely Longoria will run out of retirement savings, and become a significant financial burden on the children and grandchildren. On the bright side, she will have received more than her fair share of whatever social benefits exist at the time. If any.


Sometimes death is not the worst thing. I’ve heard of the victim’s family asking the judge to spare the killer’s life; they wanted life in prison without parole instead for him, preferably with big black dudes with testosterone squirting out their pores as roommates, and they wished him a long, eventful life. Seems a lot more vicious than death.

Intentions aside, I consider living to 120 a curse.

After the End of the Road

As of Early 2014

What I do not want:

  • Extended mourning period. Of course people will be sad (at least I hope those I deal with will!), but it is what it is. Everyone mourns differently, but it would make me happy to know that I am remembered with a smile instead of a flattened mouth, sooner rather than later.
  • No days or weeks of praying or chanting, not for my sake. People are free to do whatever makes them feel better, but please don’t impose anything (directly or indirectly) on anyone else, especially my family. To be crystal clear, no one should even ask or indirectly suggest to my family if a prayer session or a Buddhist chanting should be done. I don’t want one. Anybody can do whatever they want to make themselves feel better, but nobody should have to be forced, pressured, hinted, or even influenced to attend one of these sessions, especially in my name. That would be against my wishes and be of the greatest disrespect to me, and I will haunt you till the day I die. I mean, resurrect.
  • Formal service of any type where people you barely know come and “pay their respect”. Makes sense to neither the living nor the deceased. If I wasn’t able to earn your respect in meatspace, it would be stretching to think that being reduced to ashes could. If it is absolutely needed for work or business partners, just do the bare minimum and don’t bother my family about it.
  • Flowers, gifts, abalone towers, and especially gifted canned writings in Chinese by people who likely do not know me and whom I likely do not care about.

What I do want:

  • Family to carry on knowing that I love them always (duh).
  • People to remember me from my good days (not many).
  • People who offended me to know that I do not hold a grudge (I’d be dead, so it would be difficult); for those that I have offended, forgive me (or carry the grudge to your grave, whichever you prefer).
  • Organs donated, if viable (ha!).
  • Cremated soon. I don’t like it THAT cold.
  • My children to never lose your sense of curiosity, to be careful and critical thinkers, to never let someone else think for you (groupthink), to always be open to change your minds based on facts and sound arguments (not opinions and assertions), to know exactly what it would take to change your minds, to have no cow so sacred it cannot be slain. Study some psychology and philosophy; it will help you greatly in life, as will a good sense of humor. After all, money is not omnipotent. Although I admit it’s pretty damn close.
  • Most of my ashes should be kept as part of the Liang’s Family Great Ash Collection (it’s a family thing). No matter how colorful or what a steal it may seem to be, no plastic urn please.
  • Family to take a vacation together and bring a very small bag of ashes to scatter there. Yes, MY ashes please. If the “ashes” are too bony, pick the smaller, inconspicuous pieces or grind ‘em up (probably won’t hurt me). It had better be a fun place. Repeat at least once a year, and as often as necessary, until money or ashes runs out, whichever comes sooner.
  • An informal gathering in place of a service, which should be a celebration of my life and not a reminder of my death. No stage, no microphone, no elaborate setup. Keep it small and intimate and happy. Happy music, food, beer, wine and booze, upbeat atmosphere. For those that want to, they can share a memorable moment about me with others, be it funny, poking fun at me, heartwarming, or anything, good AND (not or) bad, as I want to be remembered for who I was, flaws and all. No suits or ties, no dark colors unless that’s what you normally wear. For the crybabies, please do so in private.
  • Afterwards, have a gathering of friends in my house, doing what we usually do. If I was still playing poker, there should be a poker table with the usual players playing the usual game. A seat should be left empty for me, with an unlit cigar and a glass of whiskey. If I am in the big blind, don’t steal it unless you have a premium hand (AQ+ or pair >9). Trust me, you don’t want to have a reputation of stealing from dead people. Leave a seat at the table for me during dinner, with a glass of wine and a bottle of beer, for this day only. For those that want to, take a poker chip as a keepsake upon leaving (sorry, no cash value).
  • For those who choose to visit my family, please honor me by raising a glass (or mug) of your favorite beverage, alcoholic or not, assuming I have it in stock. Don’t worry, if I have done my job, all the good stuff will be gone. Tip: if it’s non-alcoholic, better bring it yourself.



  • Keep those prying eyes away from my browsing history (yes, you)
  • If my death is bothering you and you need someone to commiserate with, take comfort in the fact that sometimes it bothers me too.

Thoughts about End-of-Life

As of Early 2014

Few things brings one’s own mortality to the foreground than watching a loved one leave.

It is full of difficult decisions and tradeoffs. Although I fantasize that my thinking will always be clear as I age, it is simply unrealistic to expect so; and wishful thinking does not constitute a plan. In reality, my cognitive skills will likely decline with age. I expect that the decline will be (or has been!) imperceptible to myself. That is, I will be under the illusion that my mind is as sharp as it has always been, and perhaps even “wiser by experience” as I age, when in reality my thinking may already have deteriorated significantly. Without objective measures it would be tough to convince myself of the deterioration; and at some point, even with objective measures, it is possible that no amount of evidence could. As I like to say, trust is hard to come by; hell, I don’t even trust myself (well, my future self).

So in theory, a living will/advance health care directive should work. However, it is important for me that my wishes not be contradicted or overturned by my future self in a possibly compromised state. To me in my current, fully rational and informed state (yes, wishful thinking), it is far more important to me that instructions be followed as I direct them now, and not what I might otherwise instruct in a state of distress or panic. I want to be remembered as I currently am now, and not who I hope I will not become towards the end. For example, I do not know if I might, in a state of despair and/or diminished thinking, say, turn to a religion (monotheistic or otherwise), superstitious thinking, magical thinking, or unproven forms of folk/alternative medicine. It is a tough call and probably unusual, but I would like to explicitly state here that any changes made to my advance health directives after I become seriously ill and/or impaired should be ignored. If that is not legally possible or if it is overridden for any reason, I would like my original, unmodified directives to be made available to those whom I care about or those who care about me. It may sound silly since I would be dead or impaired and shouldn’t matter to me; however it is important to me now that those who remember me do so with the right perspective.

I also want to be fully informed of my medical condition, no matter how bad it is. If I cannot express my wishes, the default is to go hospice if there is no reasonable chance of recovery. No heroic efforts, no hail marys, especially if the treatment is experimental or scientifically unproven in nature, and/or may carry other risks or discomforts. I am not afraid of death. However, I am afraid that I will not be able to plan out the remaining time I have left. I want to see the end of the road, whether long or short, and if there are monsters on the way, so be it. If I show signs of depression, hallucination, or other types of mental problems, I want my caregivers to give whatever medication is necessary and respect my directives made before my mental problems have occurred. Only in the case where serious mental deterioration has occurred, and informing me fully of my medical condition would seriously adversely affect my wellbeing (such as suicide) do I waive the right to be fully informed.

I set up an account on, as it is a bit more comprehensive than ordinary living wills. Five Wishes is an interesting version but a bit too spiritual for me – I would have to cross out a lot. What also irritates me is the fact that the Five Wishes version seems more for the living than for the person facing death. Perhaps that’s what makes more sense, but somehow it still rubs me the wrong way.