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“When Blood Breaks Down”: It Can Break Your Heart

By CHADI NABHAN, MD, MBA, FACP

The goal for me and for my clinical and research colleagues is to put ourselves out of a job as quickly as possible”. This is how Mikkael Sekeres ends his book “When Blood Breaks Down” based on true stories of patients with leukemia. I share Mikkael’s sentiments and have always stated that I’d be happy if I am out of a job caring for patients with cancer. To his and my disappointment, this wish is unlikely to ever come true, especially when dealing with leukemia.

With almost 15 years of experience, Sekeres possesses a wealth of knowledge and patient stories making him the ultimate storyteller taking us along an emotional journey that spanned hospital rooms, outpatient clinics, and even his car. We get to know Mikkael the person and the doctor and immediately recognize how difficult it is to separate these two from each other. With hundreds of patients he has cared for, Mikkael could choose which stories to share. He decides on 3 patients, each with a unique type of leukemia and a set of circumstances that makes their story distinct. While I don’t know for certain, his selection likely reflected his ultimate goal of writing this book. It was about sharing life lessons he had learned from his patients–lessons that we could similarly learn—but it was also about giving us a glimpse of history in medicine and the progress that has been made in treating leukemia.

We get to know the three main characters of the book very well. David is an older man with acute myeloid leukemia (AML), Joan is surgical nurse who suddenly finds herself diagnosed with acute promyelocytic leukemia (APL), and Mrs Badway is a pregnant woman who was in her 2nd trimester when she was diagnosed with chronic myeloid leukemia (CML). While learning about their illnesses and family dynamics, Sekeres educates us about the various types of leukemia and enlightens his readers about so much history that I found fascinating. I did not know that the Jamshidi needle that I have used on so many patients to aspirate their bone marrows was invented by an Iranian scientist. Maybe I should have known, but I didn’t, that FISH was developed at Yale in 1980 and the first description of leukemia has been attributed to a French surgical anatomist, Dr. Alfred Velpeau in 1827. Somehow, I always thought that Janet Rowley discovered the Philadelphia chromosome, but Sekeres corrects me when he pictured Peter Nowell and David Hungerford who discovered that chromosome in 1961. As a reader, you might be more drawn to the actual patient stories, but the geek in me enjoyed the history lessons, especially the ones I was unaware of. Sekeres inserts these pearls effortlessly and with perfect timing. He does that so seamlessly and naturally that you learn without realizing you are being taught.

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COVID-19 and Opening the Country: Lessons from 1918 Philadelphia

By CHADI NABHAN, MD, MBA, FACP

Everyone has an opinion on whether and when we should open the country. Never in the history of America have we had so many “correct” theories and experts to pontificate on a new pandemic. But somehow, few seem to recall history or attempt to learn from it.

Over a century ago, almost 100 million people out of a world population of 1.8 billion lost their lives to the so-called “Spanish Flu”. At 8.5 million casualties, the death toll from World War I pales in comparison. In the US alone, we lost over 675,000 people in one year to this pandemic. In fact, we lost more people to the 1918 flu than to World War I, World War II, the Korean War, and the Vietnam War combined. It was estimated that 5-10% of young adults had died. Nothing has ever come close in devastating the world’s population.

In early 1918, Dr. Miner from Haskell County in Kansas encountered several patients with a severe form of the flu that faded away by March 1918. He was concerned enough to report his observations to the US public health services, who published his concerns but then ignored the issue; there were more pressing problems facing the world, namely World War I. But in Camp Funston, a military complex, soldiers were faced with such cold weather and inadequate clothing that 7,000 of them suffered from the flu and nearly 100 died. Still, these warning signs didn’t seem alarming enough to prevent 1.5 million soldiers from crossing the ocean and going to war in Europe.

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Lessons from Zika in the Era of COVID-19

By CHADI NABHAN, MD, MBA, FACP

If you are a soccer fan, watching the FIFA World Cup is a ritual that you don’t ever violate. Brazilians, arguably more than any other fans in the world, live and breathe soccer—and they are always expected to be a legitimate contender to win it all. Their expectations are magnified when they are the host country, which was the case in 2014. Not only did the Germans destroy Brazilian World Cup dreams, but less than a year after a humiliating loss on their turf, Brazilians began dealing with another devastating blow: a viral epidemic. Zika left the country scrambling to understand how to manage the devastation caused by the virus and grappling with conspiracies theories of whether the virus was linked to the tourism brought by hosting the FIFA World Cup.

How did I become so interested in what happened in Brazil five years ago? Well, social distancing and being mostly at home in the era of COVID-19 seems to energize reflection. Watching politicians on TV networks blaming each other and struggling to appear more knowledgeable than scientists makes me marvel at the hubris. My mind took me back to several prior epidemics that we encountered from Swine Flu to Ebola, and I couldn’t help but think about the lessons lost. What did we miss in these previous crises to land us in this current state where Zoom is your best friend and you are more interested in commenting on tweets than doing a peer-review? One cannot help but wonder what is so different about this coronavirus that it has paralyzed the globe.

I decided to take a deep dive into the Zika epidemic in a hopeful effort to better understand the present public health crisis. I started by reading Zika: The Emerging Epidemic, by Donald G. McNeil Jr, who also covers global epidemics for the New York Times. The book is a fascinating read and offers illuminating parallels to the current failings we are seeing with national and global health protection agencies during the COVID-19 pandemic.

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“Essential Oncology”: The COVID Challenge

By CHADI NABHAN MD, MBA, FACP

One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?

This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.

As an oncologist, these various views, sentiments, tweets, and posts give me pause. I understand the rationale to minimize patients’ exposure and thus prevent transmission. However, reconsidering what we should deem “essential” has made me reflect broadly on our method of providing care. Suddenly, physicians are becoming less concerned about (and constrained by) guidelines and requirements. Learning how to practice “essential oncology” may leave lasting changes in our field.  

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“Chasing My Cure”: A Book Review

By CHADI NABHAN, MD, MBA, FACP

Have you thought about your own mortality?

Who hasn’t, given the frequency of seeing death and grief depicted in the media or through real life encounters with friends, relatives, neighbors, or patients? These incidents trigger uncomfortable and sometimes uneasy thoughts of how we might personally deal with potential illness and disease. The same thoughts are soon displaced by the busyness of living. 

Despite dealing with the death of his mother from a brain tumor, we learn David Fajgenbaum was healthy, living life to its fullest, and a future doctor in the making. He may have thought about his own mortality as he grieved the death of his mother, but likely never imagined anything dire would happen to him. Fajgenbaum was pushing forward on several fronts, including leading a non-for-profit organization for grieving college students, symbolically named “Actively Moving Forward” or “AMF” after his mother’s initials, all while first playing college football and then attending medical school. By all accounts, this was a vigorous young man, meticulous about his diet and physicality.  When he became ill, it was a blunt reminder that life is unpredictable.

In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill.  He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students. 

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Can we move on?

By CHADI NABHAN MD, MBA, FACP

Every so often, my cynical self emerges from the dead. Maybe it’s a byproduct of social media, or from following Saurabh Jha, who pontificates about everything from Indian elections to the Brexit fiasco. Regardless, there are times when my attempts at refraining from being opinionated are successful, but there are rare occasions when they are not. Have I earned the right to opine freely about moving on from financial toxicity, anti-vaxers, who has ‘skin in the game’ when it comes to the health care system, the patient & their data, and if we should call patients “consumers”? You’ll have to decide.

I endorse academic publications; they can be stimulating and may delve into more research and are essential if you crave academic recognition. I also enjoy listening to live debates and podcasts, as well as reading, social media rants, but some of the debates and publications are annoying me. I have tried to address some of them in my own podcast series “Outspoken Oncology” as a remedy, but my remedy was no cure. Instead, I find myself typing away these words as a last therapeutic intervention.

Here are my random thoughts on the topics that have been rehashed & restated all over social media outlets (think: Twitter feeds, LinkedIn posts, Pubmed articles, the list goes on), that you will simply find no way out. Disclaimer, these are NOT organized by level of importance but simply based on what struck me over the past week as grossly overstated issues in health care.  Forgive my blunt honesty.

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The Death of Cancer: Book Review and Reflections

By CHADI NABHAN MD, MBA, FACP

Some books draw you in based on a catchy title, a provocative book jacket, or familiarity with the author. For me, recollections of medical school primers written by the renowned lymphoma pioneer Vincent DeVita Jr. and my own path as an oncologist immediately attracted me to “The Death of Cancer.” I felt a connection to this book before even reading it and prepped myself for an optimistic message about how the cancer field is moving forward. Did I get what I bargained for?

Co-authored with his daughter, Elizabeth DeVita-Raeburn, DeVita brings us back decades ago to when he had just started at the National Cancer Institute (NCI) under the wings of Jay Freireich and Tom Frei. At the time, he was a clinical associate and a “chemotherapist”; the field was ultimately renamed and defined as medical oncology. (Note to self: I am ecstatic the field was renamed; I would prefer to be called a medical oncologist anytime than a chemotherapist, but that’s just me). He recounts how chemotherapy was frowned upon in favor of the two preferable ways to treat cancer at the time: surgery and radiotherapy. DeVita eloquently describes how his mentors were ridiculed when they announced their pursuit to cure childhood leukemia using combination chemotherapy; their approach and determination provided him with inspiration to push his research further. He goes on to describe in a fascinating manner the way he designed the MOPP regimen, which cured many patients with Hodgkin lymphoma. He recounts events when he presented his own MOPP data, and how he was verbally attacked by radiotherapists who claimed his data were insufficient and attempts to drive them “out of business”. Even in 2018, my radiation oncology colleagues protest when medical oncologists challenge the role of radiation therapy in Hodgkin lymphoma. I have actually grown tired of attending debates between any two prominent lymphoma figures discussing whether to use radiation or not in such setting; there are better topics to argue about, like who might win the Super Bowl.

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