Oncology

flying cadeuciiPhysician–Assisted–Suicide; the collaboration of two through a professional relationship, to cause the death of one.

Ever since Socrates took hemlock, suicide has been part of society, sometimes supported, often condemned.  Today, many argue that we have a right-to-die, sort of an infinite extension of free speech or thought.   Regardless, to actively involve doctors is a unique distortion of the medical arts, as if stopping a beating heart can somehow mend disease.  For a healer to take life is bizarre and threatens the physician-patient relationship.  If individuals really want and require assistance to die perhaps there is another solution.

A long trail of vital documents marks our lives. These include birth certificate, diplomas, driver’s and marriage license, advanced directives, wills and most recently the POLST. Perhaps we should create a new personal document.  Its purpose would be to give each person not only permission to kill themselves, but access to the means.  A permit controlled by the patient and only their responsibility.  A passport for dying.  A Suicide Certificate.

The Suicide Certificate would be a kind of application.  A legal checklist, which once complete would allow the individual to die by their own hand, but in a controlled and definite manner.

What would go on this form?  First, basic demographics; name, birth-date, address, social security number, etc.  It is important to confirm that the right person is filling out the form.  A photograph might be a good idea.

Next, statements regarding right-to-die laws.  This could include a review of the sanctioned methods available, as well as the legal indications and limits for committing suicide.  It might remind the applicant that a terminal disease is required, what is and is not a qualifying medical condition, and that suicide pacts are discouraged and therefore forbids sharing the lethal prescription. The whole form might start on-line and as part of the process an instructional video must be viewed and review answers given correctly, before it can be printed.  Alternatively, an app could be developed.

Continue reading “The Right to Die: The Suicide Checklist”

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asco 2014 entranceThe American Society of Clinical Oncology recently made public nearly all of the abstracts — more than 5,000 pieces of research — that were selected for the ASCO annual meeting, which kicked off in Chicago on the last day of May.

Sifting through those 5,000 abstracts would be an almost inhuman task: each abstract contains 2,000 characters. That’s 10 million characters of information about oncology created by experts that’s now available for the public to parse.

But as remarkable as the ASCO abstract drop is, that research is not the only overwhelming trove of communication on cancer created by doctors. One ASCO abstract (based on research by me and W2O colleagues Greg Matthews and Kayla Rodriguez) tells story of how, over the course of 2013, U.S. doctors tweeted about cancer 82,383 times. At 140 characters a tweet, that’s nearly 12 million characters.

We know there were 82,383 tweets because we counted them. Using our MDigitalLife database, which matches Twitter handles with verified profiles from the government’s physician database, we scanned all tweets by doctors for mentions of dozens of keywords associated with cancer over the course of calendar year 2013.

Continue reading “What Twitter Tells Us about the War on Cancer”

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flying cadeuciiAfter my last post about “the gift of cancer” I must say that CLL has felt much less like a gift this month.

Joining the ranks of those with “a diagnosis” has given me a some insight into what our patients face all the time.

Recently, I received my second dose of humility.  I capped off a truly exhausting week in the hospital with a routine lab follow-up.

The last day of my 85-hour week I had my CBC checked, and my platelets dropped from the 100s to the 30s.

My first reaction was denial.  Lab error.

Unfortunately, they dropped further the next day and I realized that the little red bumps on my legs weren’t some skin reaction, but petechiae.  Bummer.  Turns out that in addition to the 2% of people diagnosed with CLL under age 40, I also joined the 20% who develop idiopathic thrombocytopenic purpura (ITP).

The treatment of choice for ITP is prednisone 1mg/kg.  So after a visit with my oncologist, I started 80mg of prednisone.

I realized with more than a little chagrin that I have a double standard about therapeutics. I was surprised at how much I despise being on prednisone.

I had never taken it before, and I would guess that I prescribe it every week, if not every day, that I work in the hospital. I have always felt that prednisone is fine for my patients to take.

Steroids work to help clear up that asthma flare, quickly improve that gout pain, or even help with a burst of energy in the last days or weeks of life for a terminal patient.

But for me? No thank you.

Continue reading “The Gift of Cancer”

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flying cadeuciiI recently read a blog by Dr. Danielle Ofri in the New York Times “Well” blog about how as a physician she learned to respect the patient’s wishes even when they contradict her professional inclinations. It’s called Doctor Priorities vs Patient Priorities.”

She writes that the patient is looking through a “wide-angle lens” that takes in the whole of his life while the doctor’s lens is “narrowly focused on the disease that pose[s] the gravest and most immediate risk”. She saw her challenge as entering into dialogue with her patient in order better to understand the wider perspective of his whole life and to work with him to find the most acceptable way to deal with his disease.

If only Dr. Ofri were an oncologist. If only she were my oncologist. My last appointment with my onco, Dr. G, was a disaster. Not only have I not been back to her, I have not gone to any oncologist since then. Part of that is because I don’t want any treatment at this time; that’s still true.

But if I am going to be very honest, and I try to be that always, it is also because of that disastrous appointment with Dr. G.

First of all, she would not respect my decision not to have any more chemo and refused to order any scans unless I would a priori agree to chemo if she decided it was indicated. She also mocked me. It took a long time for me to tell that second bit. In fact, from that day in August 2013 until just recently—seven months!—I only told one or two other people about what happened.

The evening of that last appointment, Dr. G called me at home to continue the argument. I found myself apologizing for causing her distress. Yes, I know that’s ridiculous, but that is how I react to being bullied. Borrowing the words of a friend who really gets it, I apologize to others for their hurtful behavior and then I internalize it. I haven’t talked about Dr. G mocking me because I feel ashamed.

Continue reading “Whose Cancer Is It, Anyway?”

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What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common?  They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.

Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity?  Look into our subconscious to explain everyday behavior?  Give basic healthcare to everyone?  Ludicrous.  That is why we named these advances after these men.

As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA).  The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:

-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.

-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.

-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.

-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.

-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.

Continue reading “The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act”

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The general practice of oncology seems to come in waves of disease.  One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU.  This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.

First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing.  We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”).  What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery.  More than having cancer, Allen is hurt by the feeling it should have been him.

Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland.  Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal.  Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating.  What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike.  He has recurrence of prostate cancer, previously treated with surgery.  Now Mike needs RT.  Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
Continue reading “Prostate Cancer: Not a Good Week”

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May 30-8:12pm: 27 yo teacher, Pam S., is out for her evening run. The delicious evening air fills her nose and lungs. She feels strong, healthy, and alive.

May 30-8:13pm: Pam pushes up a gentle hill. She feels sudden and severe pain, as if stabbed deep by a flaming splinter.  Pam stops, almost falling.  She struggles the mile home. The searing throb begins to fade. A long hot shower gives some relief.

June 3-5:45am: The torment progressed through the weekend and curled around pillows, drenched in sweat, she has not slept all night.  As traces of sunrise light frame her bedroom window, she decides to get medical care.

June 3-9:22am: Pam tells her story to her Primary Medical Doctor (PMD) and is examined.  Her pain is intense with any movement and he is worried. He orders blood work, pain medication and calls an orthopedic surgeon. The PMD completes his history and physical report, as well as his differential, in his Electronic Medical Record (EMR).  The note is transmitted instantly to the surgeon.

June 3-9:59am: STAT blood work is drawn at a lab down the street.

June 3-10:37am: Pam picks up the pain medication.

June 3-11:25am: The orthopedic surgeon reads the PMD’s note, listens to Pam’s story and examines her.  He orders an emergency MRI.

Continue reading “From the Case Files of the Robert Wood Johnson University Hospital, Dec 2015″

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I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy.  Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out.  Day-by-day he lay in bed, as he grew weaker and multiple systems failed.  No one contacted me.  Finally, he sent an email to a doctor 3000 miles away, in California.  That doc forwarded the email to me.  I sent the patient to the hospital.

Did we rush to the emergency room, to salvage his life?  Of course.  Were there innumerable tests, complex treatments, multiple consults and an ICU admission?  You bet.  Did I patiently explain to him what was happening?  Yes.  Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor?  Did I remind him what I expect from him and what he can expect from me?  You better believe it, I was really pissed!

The practice of medicine for most doctors is fueled by a passion to help our fellowman.  This is not a vague, misty, group hug sort of passion.  This is a tear-down-the-walls and go-to-war passion.  We do not do this for money, fame, power or babes; we do this because we care.  Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning.  Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.

Continue reading “Why Is the Doctor Angry?”

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We need heroes.  Heroes show us light in the darkness, the way to the miraculous and ignite a fire in our soul to survive.  They prove what is truly possible, through the fog of the impossible.  We mourn the disgrace of Lance Armstrong because he seems to have achieved Pyrrhic victory.  Let us not doubt; whatever his frailty as a man, Armstrong vanquished a terrible foe; moreover the path blazed is not bare, for everywhere are cancer heroes.

- The 45 year old RN raising her children while she works full time in a pediatric intensive care unit, celebrates her eighth year in remission from pancreatic cancer, treated with surgery, chemotherapy and radiation.

- The grandmother who ignored a breast mass for two years so she could care for four disabled grandchildren, and when the tumor grew to be massive, continues to take care of the children while receiving chemotherapy.

- The hospital chaplain who has suffered from cancer, sits at the bedside holding a hand, sharing a smile, saying a prayer that is heard deep in the heart and to the heavens above.

- The 71 year old with four different cancers, treated with a bewildering mix of surgery, radiation and chemotherapy, whose primary worry is the cardiac care of her husband.

- The 64 year old rescue squad volunteer while receiving chemotherapy and radiation for extensive lung cancer, assists 150 people to flee from their homes and escape the wrath of Sandy.

- The national lymphoma expert, who could be wealthy in his own clinic, instead devotes his life to teaching and research, believing he can save more lives by consulting and advising oncologists in communities around the country.

Continue reading “Replacing Lance”

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The 30,000 member American Society of Clinical Oncology is the world’s leading group of cancer physicians. ASCO is dedicated to curing cancer, supporting research, quality care, reducing treatment disparities and a heightened national focus on value. This month they released their annual Report on Progress Against Cancer, which highlights research, drug development and cancer care innovations.  This hundred-page document is important reading for anyone who wants to be up-to-date regarding cancer care.

Cancer related deaths in the United States are dropping, but still totaled 577,000 in 2012.  While world cancer research funding is rising, in the USA it continues to decrease, with the purchasing power of the largest funding source, the National Cancer Institute, having fallen 20% in the last decade, and a further 8% cut slated for January 1, 2013.   Development is dependent on government and private funding, as well as the willingness of more than 25,000 patients a year who volunteer to be involved in cancer trials.  All these critical supports are threatened. The Federal Clinical Trials Cooperative of the National Cancer Institute (FCLC, NCI) supports research at 3100 institutions in the USA.

The report discusses the many types of cancer which continue to be naturally resistant to cancer treatment, particularly chemotherapy.  In some cases, drugs do not penetrate a part of the body, such as the brain, in other cases even when they reach the tumor, they are not effective.  In such cancers the genetic code of the cancer cells has mutated (changed) such that the particular drug does not kill the cancer.  In 2012, there was increased interest in attacking each cancer cell at multiple targets either by using a single drug, which attacks in several different ways, or multiple drugs at the same time.  This concept improved cancer killing in GIST, colon cancer, certain lymphomas (ALCL) and medullary thyroid cancer.  In addition, unique targeted compounds, such as “tyrosine kinase inhibitors,” show increasing benefit in leukemia, sarcoma and breast cancer.

Continue reading “Advances In Cancer 2012″

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