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.
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.
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.
George Washington never met an Oncologist. I know this because of the Cherry Tree story. If our first President had spoken to a cancer doc, then that honesty fable would have been different. Anyone can tell the truth about cutting down a tree. It takes real guts to say to an oncologist, “I cannot tell a lie, I have a problem.”
Doctors frighten all of us. No matter how warm and congenial they are, there is always the threat of what they may say. A few words from a physician can change your entire life. An oncologist may be the scariest of all. For this reason it can be very hard for any of us to tell our doctor the complete absolute truth.
It is easier to diminish or deny pain, then describe in detail and submit to tests. Emphasizing the balance in a diet has less risk than noting it is only 600 calories. Increasing fatigue can be blamed on stress, not progressive weakness. Everyone seems to have quit smoking, despite yellow stained nails. “Social” drinking sounds better than a daily six-pack. We carefully parcel out the information we tell our doctor. It is gut level denial and it does us no good.
Physicians understand the desire of patients to limit and control the conversation. They learn to recognize incomplete and evasive answers. They try to ask questions which produce accurate information. A compassionate doctor knows that his response to a patient’s words is as important as the question asked.
Even though it can be hard, it is in our best interests to supply good information to our caregivers. Doctors cannot make correct diagnoses or order proper treatment using erroneous data. Unneeded X-rays are frequently ordered to fill gaps in information, which the patient could have supplied. Understanding it can be tough to disclose personal medical facts, here are several ideas that might make communication easier and more complete:
A year-and-a-half ago, Howard Brody of the University of Texas Medical Branch in Galveston wrote an opinion article in the New England Journal of Medicine calling on every medical specialty to develop ways of cutting the cost of care. Citing financial sacrifices that had been made by insurers, hospitals, drug and device companies in the then pending health care reform bill, Brody said physicians could do their part “if they were willingto practice more in accordance with evidence-based guidelinesand to study more seriously the data on regional practice variations.”
Toward that end, he called on each specialty to come up with a list that “would consist of five diagnostic tests ortreatments that are very commonly ordered by members of thatspecialty, that are among the most expensive services provided,and that have been shown by the currently available evidencenot to provide any meaningful benefit to at least some majorcategories of patients for whom they are commonly ordered.”
In the NEJM last week, two oncology specialists — Thomas Smith and Bruce Hilner of Virginia Commonwealth University — took up the challenge. They created a “top five” list of common oncology practices, which, if limited to situations where they were truly clinically useful, would sharply lower the cost of cancer care. Their lead paragraph noted the need for taking these steps:
Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more, and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds. This trend is not sustainable.Continue reading…
There isn’t a country on this planet where there isn’t someone dreaming of curing cancer. What if there was something even more spectacular than curing cancer? What if you could stop cancer right in its tracks and eliminate its existence. Prevent it. Squash it before it starts.
Vincent Tuohy, PhD, an immunologist at Cleveland Clinic, may be on a path toward living this dream. This month at our hospital’s quarterly meeting, Tuohy was awarded Cleveland Clinic’s F. Mason Sones Award for 2010 Innovator of the Year for his recent breakthrough that may one day prevent breast cancer and perhaps revolutionize our approach to fighting all cancers.
Tuohy has spent the past eight years working to create a vaccine to prevent breast cancer. He and his team have found that vaccination with the protein α-lactalbumin prevents breast cancer in mice. His results were published in Nature Medicine, one of the most respected science journals, last summer.
The study yielded dramatic results. A group of mice that were at high risk to develop cancer according to their genetic profile was selected. Half of the mice were given the vaccine and half were not. All the ones given the vaccine did not develop breast cancer. All the ones not given the vaccine developed breast cancer. Yes, these are mice, and human trials are yet to begin. It may be ten years before we have a finished product, but such overwhelming results are promising and exciting.Continue reading…
Radiation therapy is the most overlooked of cancer therapies. While attention has primarily been given to chemotherapy and immunotherapy, the truth is that for every 100 people who survive cancer, about 50 can principally thank surgery, 45 are alive because of radiation therapy and perhaps 5 survive due to all other therapies. As cancer death rates continue to decline, we must recognize and support the critical role that radiation therapy plays in this trend.
Of the $2.2 trillion spent by the U.S. economy on healthcare, less than one percent (about $800 million) is spent on radiation therapy equipment—this, despite the fact that radiation therapy serves as our safest, most convenient and cost-effective method of treating cancer.