Dear Ms. Jolie,
Thank you for your bravery and leadership in the battle against breast cancer. In a small way, through my patients, I understand the challenge and pain it took not only to undergo prophylactic mastectomies, because you carry the BRCA1 cancer gene, but also to reveal this deeply personal part of your life to the world (NYT, 5/14/13; My Medical Choice). You had no obligation to open your soul; your selfless act leaves those of us that treat the dread disease, in awe.
Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years. By opening up the conversation, by educating and by boldly stating that beauty, strength and health are possible, even when radical choices are made, you open up life saving opportunities for many. Mastectomies may not be the answer for all women, but the very idea that cancer can be prevented, instead of simply waiting in fear, is earth shattering.
Women and men will now better understand the genetic risks for cancer, be exposed to the different options which are available in the prevention of cancer and know that it is possible, whatever path is taken, to continue with full lives. You have made it easier for patients, their families and physicians to have vital discussions.
The announcement of your surgery coincides with a critical legal battle, the deliberations of the United States Supreme Court regarding BRCA genetic testing. You have put pressure on the Court to find against Myriad Genetics Corporation in the company’s attempt to protect their expensive monopoly of the breast cancer genetic assay. Thus, the Court will have the opportunity to reduce the cost of testing, which as you note, can run thousands of dollars per patient.
Your action changes the war against breast cancer. You have prevented the suffering of thousands and given them the opportunity to go on with life and be part of what is truly important, families and communities.
Thank you for your remarkable sacrifice.
James C. Salwitz, MD
James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.
Filed Under: OP-ED
Tagged: Angelina Jolie, BRCA1, Breast cancer, Cancer, James Salwitz, Screening
May 14, 2013
After a terribly painful and debilitating illness, Steve died. He had been treated for Stage 2 Hodgkin’s Disease with a series of intense therapies including German enzymes, American antineoplastins, Mexican naturopathy and Chinese Herbs, complemented by focused meditation, innumerable vitamins, extreme diet modification and acupuncture for severe pain. He fought the cancer with every ounce of his being, doing everything to survive, except the one thing that had an 85% chance of cure; chemotherapy.
I was struck this week by a comment on my website, which bemoaned the highly disorganized state of “alternative medicine” in this Country and in particular the “paltry sums” for alternative research funding by the National Institutes of Health (NIH). The writer suggested that not only could the quality of health be improved with alternative medicine studies, but would go a long way towards saving health care dollars.
It seems to me that the idea that we need more Complementary and Alternative Medicine (CAM) research goes right to the core of the confusion between so called “conventional medicine” and CAM. There is a major difference between the medicine practiced by board certified, classically trained physicians and that of alternative practitioners. That difference is research and data.
If an MD or DO is treating a cancer patient and that patient asks to see or understand the basic science and clinical studies which support the recommended therapy, that published data is readily available. Standard oncology treatment goes through 10-20 years of research, from the test tube, animal studies and through a series of supervised human multi-phase trials, until it is approved and offered to patients. Each step is refereed by competing and critical PhD and physician scientists and must be published in peer-edited journals for general review and criticism, all of which is public and transparent. Where it is not, and when people attempt to manipulate or falsify the system or data, massive blowback eventually occurs.
Continue reading “Choosing Alternative Medicine”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: alternative medicine, alternative research funding, CAM, Cancer, Chemotherapy, conventional medicine, Hodgkin’s Disease, James Salwitz, placebo
Feb 13, 2013
Here is a little appreciated fact: Patients cannot order medical care; they can only accept or refuse it.
Only a doctor can order medical treatment. In an extreme medical situation, the doctor can offer CPR, but it is the patient’s job to accept or reject.
Any patient can refuse CPR. This refusal is known as Do Not Resuscitate or DNR, and for obvious reasons needs to be made ahead of time. The question is, when is making the decision to be DNR appropriate?
A further definition is needed. DNR (and its colleague, Do Not Intubate, DNI) is not the same as DNT, or Do Not Treat. A patient, at their discretion, may receive maximal medical care, including drugs, dialysis and surgery, and still be DNR. The DNR order in that situation is simply a line that the patient will not allow the doctors to cross. “Do everything you can to help me, but if it fails I do not want to end my life on a machine or with some gorilla pounding on my chest.”
On the other hand, a DNR can be a part of a hospice or palliative care program, so that all care is focused on comfort and not treatment. It is even possible, in very unusual circumstances, to receive hospice care without being DNR. A DNR order is like any medical decision, it can be changed if appropriate. DNR is not the same as “pulling the plug.”
How aggressive to be in receiving medical care is a personal decision. In order to make certain that our individual desires are followed it is critical that, as much as possible, these decisions be made ahead of time. This avoids panic, confusion, and guilt. In that spirit, let us review a few cases.
Ben is a 54-year-old gentleman with lung cancer, which has spread to bones and liver and is growing despite the third chemotherapy. His doctors inform him that a fourth chemotherapy has a 5% chance of helping him and a 20% chance of killing him. He wants to try the chemo. His physician says, “OK Ben, we will order the chemo but if things fall apart and your body starts to fail and we cannot fix it, do you want to be put on a machine?” Do you think Ben should make himself DNR?
Ben made himself DNR. He survived the chemo, but the cancer progressed and he died one month later.
Continue reading “To DNR or Not to DNR”
Filed Under: Uncategorized
Tagged: Cancer, Chemotherapy, CPR, DNR, End of life decisions, James Salwitz, Oncology
Dec 14, 2012
Terry is a particularly difficult patient. She is not hard because of her cancer, which is in remission, nor is there a problem with pain, of which she has little, and Terry is not particularly demanding for the nursing staff. No the real problem, the challenge, the thing that makes her so difficult is that Terry is married. Terry is married to Dr. P and he is a particularly difficult man.
Terry’s husband loves Terry very much. He wants her to have the very best care. Dr. P makes certain that all the doctors know everything that is going on, all the time; he makes sure the nurses are on top of every detail; he demands the best from the all the hospital staff. In fact, Dr. P works so hard to control Terry’s care, to stay on top of her case, to monitor every moment, it is nearly impossible to take care of Terry.
There are many challenges for doctors taking care of other doctors or their families, or, in reverse, there are many challenges for doctors when they seek care for themselves and their families. The result of this conflict is often inferior medical care. Therefore, wanting to honor and help doctors get good quality treatment let us take a moment to review the doctor verses doctor verses medical system dilemma.
First, it is hard for doctors to decide where to go for medical care. If you stay in the same community where you practice you lose some privacy and perhaps even respect in the physician community. Who do you chose and how do you avoid offending the other physicians you do not use? If you leave your own area, you lose the convenience and familiarity of getting care close to home.
Continue reading “The Doctor as Patient”
Filed Under: Uncategorized
Tagged: Cancer, caregivers, doctor versus doctor, Family, James Salwitz, layman
Nov 4, 2012
Now here is a novel idea to save lives and stop the cancer plague; stop trying! Sounds as crazy to me, as it does to you, but this idea actually may have merit. Some smart people are saying that we have spent too much money for little gain, thus it is time to give up and by retreating win more battles in the war on cancer, than by charging ahead.
The Cancer Prevention and Research Institute of Texas (CPRIT) is the second largest cancer research agency in the United States, after the National Cancer Institute, controlling a pot of $3 billion dollars, most of which funds basic science and clinical research. At recent hearings, university scientists and leaders in biotech proposed that CPRIT cut back on the money it is pouring into laboratories. As Professor John Hagan of the University of Texas proclaimed, “If people didn’t get cancer in the first place, CPRIT would accomplish much of its mission.”
This radical idea was echoed in a scary article in the September issue of Lancet Oncology, entitled “First do no harm: counting the cost of chasing drug efficacy.” This editorial reviewed data, which shows that between 2000 and 2010 many new cancer drugs produced marginal extensions in survival and simultaneously increased risk of treatment associated death and side effects. The Lancet authors emphasized the vital need as we develop new therapies to carefully measure both benefit and harm before FDA approval and for careful post-marketing follow up after drugs are released to the general population.
Now in reality no one is saying that we should shut down cancer research labs and simply hope for the best. Eventually we will completely cure this disease and basic science, as well as the development of new therapies, is key to that future. Perhaps what we should hear from these words is an idea about a different balance in health and healthcare.
Continue reading “Stop Cancer Research?”
Filed Under: THCB
Tagged: Cancer, Cancer Prevention and Research Institute of Texas, cancer research, chronic disease, health maintenance, James Salwitz, life span, prevention
Oct 22, 2012
There was a night when I was in training that all the decisions, disasters and chaos, which are the practice of medicine, caught up to me. In those dark hours, I felt practically despondent. What I had seen left me in tears and overwhelmed by the tasks in front of me.
At that moment a wise attending physician took a moment to sit with me. Rather than tell me how wonderful a doctor I might someday become or brush away my errors, he validated my feelings. He said the best doctors cared, worked hard and sacrificed. However, that the basic driving force is fear and guilt. Fear for the mistakes you might make. Guilt for the mistakes you already had. How I handled those feelings would determine how good a doctor I became.
I have reflected on those words over the years and tried to use that sage advice to learn and grow. Focused properly, guilt gives one the incentive to re-evaluate patient care that has not been ideal. It drives the study and the dissection of past decisions. Nonetheless, excessive guilt can cause a doctor to avoid completely certain types of cases and refuse even the discussion of those medical issues.
Fear of error drives compulsive and exact care. It helps doctors study and constantly improve. Taken too far it can result in over testing, avoidance and over treatment. The art of medicine requires the practitioner to open his heart to criticism and be strong enough to build from failure.
Some years ago, I saw a patient who had leukemia. I concluded that the patient’s low blood count was because of this blood cancer. This was correct. I missed that in addition to the leukemia she was bleeding from a stomach ulcer. By the time another doctor spotted the ulcer, the patient was sicker than she might have been, had I made that diagnosis earlier.
Continue reading “Moments of Failure”
Filed Under: Uncategorized
Tagged: compassion, Diagnosis, failure, fear, James Salwitz, Medical Education, Medical errors, Oncology, patient-doctor communication, Training
May 25, 2012
Recently a patient with advanced lung cancer was admitted to a local hospital. Pain in his abdomen was diagnosed as a gallbladder infection.
Because he had metastatic cancer, in addition to the new problem, the patient and family decided that if things deteriorated he should not be given CPR or put on a respirator. A Do Not Resuscitate (DNR) order was entered in his chart. Treatment for the gallbladder was continued, but it was decided that there was a line that the doctors would not cross.
This made sense to me.
Try conventional therapy, but if he was too weak to recover, then do not continue treatment which could cause more suffering than benefit. Give him the opportunity to survive the gallbladder problem, but respect the terminal nature of the greater disease. We were all gratified when his pain and fever went away, and he recovered from the emergency.
When we were discharging him from the hospital, a surprising thing occurred.
The patient and family requested that since he had survived the infection, that the DNR be reversed. They decided that when a sudden new major medical complication occurred, that CPR be performed and he would be placed on a respirator. The clear protective line vanished.
In difficult lengthy discussions with the patient and family, it became clear that they were riding tides of emotion. When things looked better, they focused on life and “cure.” When things grew worse, they were ready to withdraw. They became defensive and angry at the suggestion that this decision might cause suffering. We were not able to redefine limits to his care.
Continue reading “Crossing the Line”
Filed Under: THCB
Tagged: CPR, DNR, James Salwitz, Lung cancer, Oncology, Palliative Care, The Insider's Guide To Health Care
Apr 24, 2012