News organizations used Dr. Judah Folkman’s death to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.
We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.
Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.
Two recent research papers remind us that it may be difficult to cut U.S. healthcare spending without harming quality. The first, written by a research team led by University of Chicago economist Tomas Philipson, appears in the latest issue of Health Affairs and has deservedly garnered a fair bit of media attention. The authors examine cancer spending and survival times for patients in the United States and ten European countries during the period 1983-1999 (later data were not available.) Their data confirm what we already know about health spending; the average cost of treating a cancer patient was about $15,000 higher in the United States. But the data also show that the typical U.S. cancer patient lives nearly two years longer; most of the difference is attributable to prostate and breast cancer patients. The gain appears to be due to greater longevity rather than early diagnosis. Using generally accepted measures of the value of a life, they conclude that the benefits of additional health spending outweigh the costs by a factor of 4:1 or higher. The latter calculation does not consider QALYs (quality adjusted life years) and so may be overstated. The authors acknowledge that other nations may do a better job of cancer prevention, so that their overall approach to cancer may be superior to that in the U.S., but they can find no evidence of this one way or another.
Philipson’s study suggests that U.S. healthcare consumers may get a substantial bang for their higher bucks. Maybe the U.S. system is not so inefficient after all. What about efficiency within the U.S. system? Some providers are far more expensive than others. Is the higher cost worth it? A new study by a team led by MIT economist Joseph Doyle, and released as an NBER Working Paper, suggests that you may get what you pay for within the United States. Doyle and his colleagues ask whether higher cost hospitals in the United States achieve better outcomes than lower cost hospitals. It is not easy to answer this question, because higher cost hospitals may admit more severely ill patients. This results in a statistical problem known as selection bias that is difficult to eliminate with available severity measures.
What could be more pressing than ending suffering and death from cancer — a disease that kills 155 people every day in California?
A yes vote on Proposition 29 on June 5 to increase the tobacco tax by $1 will save lives from cancer and other lethal diseases caused by tobacco, protect kids from the tobacco industry’s predatory marketing, ease the enormous economic burden of tobacco use on the state and fund groundbreaking medical research on the leading killer diseases.
Yes on 29 is an opportunity to tell Big Tobacco that enough is enough. That we’re tired of the industry’s relentless assault on our children, our health and our economy. Proposition 29 was written by the state’s leading public health groups – the American Cancer Society, American Heart Association and American Lung Association – to empower Californians to fight back against Big Tobacco’s ongoing campaign of addiction and death. Proposition 29 will also help reverse tobacco’s debilitating drag on California’s economy, saving the state billions of dollars in health costs.
The tobacco industry spends every minute of every day surreptitiously recruiting new customers: our kids. During the past decade, Big Tobacco invested 10 times more on marketing its deadly products in California than the state spent on educating the public about its harmful effects. The tobacco industry spends more than $650 million each year targeting our state with deceptive marketing designed to recruit their next generation of customers – and has already spent nearly $40 million to distort the truth on Proposition 29.
The industry’s efforts are devastatingly proficient: California’s kids buy or smoke more than 78 million packs of cigarettes each year. Nearly 90 percent of the smokers in California started smoking before their 18th birthday.
Supporters of the Big Data movement argue that data will change everything, but only once we break down the institutional and technological barriers that prevent us from getting at it. In his talk at TEDMED 2012 at the Kennedy Center, Stanford’s Atul Butte argues that the we already have more than enough to do real science, if only we know where to look.
Kathy heads to surgery tomorrow at 7am. She’ll be NPO (nothing by mouth) after midnight. She’ll wake at 5am, shower with Hibiclens (a antibacterial prep), and I’ll drive her to surgical check in. Prior to surgery, the radiology department will insert a wire adjacent to the titanium markers that were placed in her tumor at first diagnosis. Her surgeon will use this wire to guide the lumpectomy.
Her left breast will become smaller than her right. She jokes that her career in exotic dancing will come to an end.
The operating room will call me at the end of her procedure and I’ll pick her up. Since she’ll not have had general anesthesia, we’re presuming she’ll feel good enough for a bit of an extended ride home. The last of our chickens arrives on Friday (Buff Orpington’s) and we’ll pick them up as we drive back to our new farm.
We’ll anxiously await the results of pathology. If the margins on the lumpectomy tissue are clear, Kathy will start Radiation Therapy 1-2 months after surgery, likely late June or early July.
By Labor Day, if all goes well, this phase of our cancer journey will end, although our continued vigilance for reoccurrence will be lifelong.
I felt sad when I went to make rounds in the hospital.
One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma.
I spent a few minutes examining Dennis and chatting. He then, with a quizzical look, said, “Jim, I’m going to have to sue you. I know I’m dying. My wife Alice and the kids are still pretty young.” He saw my look of surprise and added, “You know, I don’t have much life insurance or other very significant funds for them to live on. It’s nothing personal. I know you’ve given me good care, but my wife is upset and tends to blame you for the outcome. I guess the hospital and others will be named.”
There wasn’t much more for me to say at the time except, “Dennis I can find another attending for you if you’d like.” He replied, “No, I want to stay with you.”
Dennis was a well liked family doctor. About five years earlier a “coin lesion” was discovered on a chest X-Ray. This 2cm spot in the right upper lobe had a smooth rounded border and didn’t contain calcium. A CT scan showed no enlarged lymph nodes and no other spots elsewhere. A needle biopsy of the spot was not diagnostic. We knew the spot was new because an X-Ray five years earlier was normal. He hadn’t traveled to an area where Valley Fever or other fungal infections were common.
Universal treatment standards will be the basis of future medical care. In oncology, a leading organization for the development of such guidelines is the National Comprehensive Cancer Network (NCCN). This national consortium of 21 National Cancer Institute designated cancer centers publishes state of the art recommendations. Modified continuously, these are internationally respected guidelines and cover more then 97% of cancers.
The 17th Annual NCCN Conference was held in Hollywood, Florida last month. Cancer guidelines were updated in several significant ways.
The general movement of the last 20 years has been to reduce the amount of surgery for breast cancer. The NCCN recommends that during breast saving surgery (lumpectomy) the surgeon test the first lymph node (“sentinel”). If there is no cancer in the first one or two nodes, then no more nodes need to be removed. The NCCN also stated, that if breast cancer patients have small cancers and normal blood tests, they do not need a bone scan, or CT scan.
In lung cancer patients, several procedures received new support. It is recommended that doctors use ultrasound-guided biopsy to sample lymph nodes in the middle of the chest (mediastinum) instead of surgery. The new guidelines also support the use of non-invasive surgery (Video Assisted Thorascopic Surgery, VATS) instead of open surgery to treat lung cancer. The use of VATS for lung cancer has increased more than 300% in recent years. The pathologic name for an increasingly common form of lung cancer was changed. Formally, called “bronchioalveolar”, it will now be called “adenocarcinoma in situ.” Finally, the NCCN emphasized the need for accurate genetic testing for “ALK”, before using the drug that targets this mutation, crizotinib.
When first diagnosed with cancer, I felt as if my body had not only let me down, but actually turned on me. Some of my own DNA had gone rogue, grabbed some prime real estate in my lungs, and set up headquarters. Even when forcibly evicted, the rebel cells kept returning. Their numbers grew, and soon recruits were colonizing new neighborhoods.
Attempting to slow the spread of cancer has required unyielding vigilance. Emotionally and spiritually, I believe this has resulted in an unforeseen benefit; a chance for personal growth.
Physically, it has taken quite a toll. My body has been a battleground and I am scarred inside and out. This could potentially be distressing, as we live in a beauty and youth oriented society where great measures are taken to avoid the imperfections associated with aging and disease.
I am not afraid of getting old. I hope to hell I do. And I made peace with myself some time ago. Not only is all forgiven (the whole cancer thing), I have an abiding affection for this body of mine. We’ve been through a lot together, and somehow, some way, we both just keep on going.
Imagine for a moment that you are an oncologist caring for a 53-year-old man with metastatic cancer, a person whose tumor has spread to lung and liver.
With standard chemotherapy, this man can expect to live around 12 months. That standard treatment isn’t all that expensive in today’s terms, only $25,000 and his insurance company will pick up the entire tab since he is already maxed out on his yearly deductible and co-pays.
But wait! Before prescribing the standard treatment, you find out there is a new chemotherapy on the market, one that costs $75,000 (in other words, fifty thousand dollars more than usual care) and has no more side effects than that standard treatment.
How much longer would patients like this have to live, on average, for you to feel that this new chemotherapy is warranted?
That’s not an easy question to answer. But it’s not an impossible one either. Clearly if the treatment would provide only, say, 1 day of additional survival on average, that would not amount to $50,000 well spent. Just as clearly, if this man could expect 10 years of additional life, no one would deny him this new treatment.
So when, between 1 day and 10 years, does it become a tough call whether to prescribe this new treatment?
“I should have gotten cancer last month,” she told me.
That was the first thought from my patient after she’d heard the news: her ovarian cancer would remain untreated for weeks, due to a critical shortage of the chemotherapy agent doxorubicin. Like her, several thousand patients have been affected by critical shortages of chemotherapy agents like doxorubicin (Doxil) and methotrexate—common medicines that are essential backbones of cancer chemotherapy. But hundreds of other people have also been affected by critical shortages of pills around the country—limiting the supply of critical ICU medications like intravenous versed, or tuberculosis drugs like isoniazid.
Why are these shortages happening, and what can be done about them?
The state of the problem
Doxil and methotrexate are among 287 drugs in “critical shortage” in the United States, according to the University of Utah’s Drug Information Service, which has been tracking the problem. Shortages have been mounting in recent years, up from about 74 in 2005.
At present, the US Food and Drug Administration and independent researchers have tracked the status of major drug shortages occurring throughout the country. The FDA keeps an online catalog of these shortages. What this catalog reveals is that among 178 drugs that were in shortage during the year 2010, a vast majority (132) were sterile injectable drugs. These are generally cancer drugs, anesthetics used for patients undergoing surgery, as well as drugs needed for emergency medicine, and electrolytes needed for patients on IV feeding.