a change of place

By |September 7th, 2014

Dear Readers,

Please follow my new posts at Forbes!

Thank you for your readership, comments and support,

ES

(what follows here at ML will be old posts, rotated occasionally):

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By |September 7th, 2014|Categories: Blogs, from the author, journalism||Comments Off

Contemplating Breast Cancer, Beyond October 2012

By |October 3rd, 2012

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It’s foggy today, October 3, ten years since the last mammogram I had and will ever need. I’ve been remiss in updating the blog. The reasons include family concerns and other projects. Meanwhile, I’ve been thinking about the big picture – what’s most important for progress against breast cancer in the decade ahead.

So here’s what I see, now – in terms of three priority areas: improving treatment, prevention, and education to inform treatment decisions.

Pumpkins, organized by subtype (WikiCommons image)

As an oncologist, I perceive huge strides in understanding BC since the time of my diagnosis. But these advances are largely invisible to patients because they’re in the realm of pathology and classification of different subtypes. What was essentially a 3-type malignancy with a handful of treatment options has expanded under the molecular microscope to a spectrum of 4, 10 or – what’s probably most accurate – hundreds or thousands of patient-particular conditions, depending on the level of precision by which you define a disease. I’m optimistic, because it looks as though, in my lifetime, BC treatment will be tailored to each patient. There’ll be less surgery and better drugs.

The hitch, now, is not so much with science as with funding– funding to analyze each patient’s tumor at the genetic and protein levels, funding to pay for treatments selected by patients (which might include less treatment and/or palliative care in advanced cases), and funding to educate doctors about BC subtypes and medical progress, so they might offer “modern” advice to each patient in ordinary clinics, apart from clinical trials and academic centers. Newer is not always better in medical care. Same goes for more treatment (especially when it comes to higher doses). Still, the lag between advances in BC science and application of distinct, targeted and better treatments is frustrating at best.

Some of my colleagues call for patience – emphasizing that studies need be confirmed, drugs tested in mice, etc. Their point is that we can’t jump from pathology research and new BC classifications to new therapy. But one lesson I take from progress against AIDS is that maybe we shouldn’t be so patient. At least not for young people with poor-prognosis BC subtypes or stage. We could do studies and studies of particular BC treatments, and studies of studies (those would be meta-analyses) and debate 8 or 10 years from now whether a particular drug or combination of drugs worked in clinical trials that selected for patients with an antiquated subtype of the disease. Or we could move toward “n=1” trials, with smart, well-trained physicians assessing each patient by a combination of old-fashioned physical exams and the most modern of molecular studies of the tumors, considering the options, and moving forward with individual, mini-experimental treatment plans.

I vote for the latter. If the drug works in a patient with advanced BC and the patient feels better, why not?

For people with early-stage BC, prescribing or taking new and essentially untested drugs makes less sense at first glance. That’s because standard treatments are “successful” – leading to long-term remissions and possible cures in over 80 percent of those affected. But these relatively good results may have, paradoxically, hampered development of better drugs that could obviate the need for breast-deforming surgeries and radiation in many women. The possible application of BC drug cocktails, in lieu of surgery for early-stage patients, is a huge question for the future, and one for which trials would be necessary. Just getting those projects going – applying BC science to treatment of early-stage cases – would be a step in the right direction.

As for BC prevention, of course that would be infinitely better than detecting or treating the disease. Unfortunately, I think we’re farther away from preventing the disease than we are from having effective and less brutal treatments for most patients. The problem with lifestyle modification – like staying active and not obese – is that it’s far from full-proof: You can be seemingly fit as a fiddle and get a lethal case of BC. Still, there are plenty of other health-related reasons for women to exercise and eat sensibly. As for avoiding carcinogens or, first, just knowing what chemicals contribute to BC formation and growth, the science isn’t there yet.  It’ll be a long haul before anyone can prove that a particular chemical causes this disease. That said, I advocate research in the slow-growing field of environmental oncology and wish there’d be more enthusiasm for regulating our exposure to likely-toxic chemicals.

The third priority is for improving education in math and science, starting at the elementary school level. Doctors need to understand statistics, but many don’t. They need to know about genomics and basic science in medicine. Patients need this kind of knowledge if they want to have a clue, if they want to engage meaningfully in decisions about which antibody to take, or pill, or whether they want to participate in a clinical trial of pills instead of surgery for a Stage II tumor with high levels of Her2, for example. That’d be a tough decision for an oncologist. I only wish that we could reach the point where we could have those kinds of truly informed conversations about clinical treatment of breast cancer, which happen every day.

We’ve got a lot of information in hand, but we need to learn how to apply that to more patients, faster and more openly.

All for a while. I’m open to ideas on this. Happy October!

ES

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Notes on Cholera, Old and New

By |October 25th, 2010

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Cholera was a far-away kind of affliction, almost an abstraction, when I first studied microbiology in 1984. The legendary, infectious scourge still affected people in places like Bangladesh or Indonesia, but was a treatable condition that, surely, would be eradicated within a decade or so through progress, if you could call it that, like basic plumbing and sanitation.

The tiny comma-shaped bacteria, Vibrio cholerae, tend to thrive in brackish water, the kind that’s just a bit salty from a mix of ocean and fresh sources. These sometimes stagnant watery places crop up in river deltas, like the Ganges, and coastal estuaries such as those along the U.S. Gulf Coast. We learned that you might, very rarely, pick up a case of cholera by eating contaminated shellfish like crabs or oysters.

The most common symptom of cholera is diarrhea, so rapid and voluminous that a person can die, quickly if without remedy, by straightforward dehydration. The diagnosis of cholera can be tricky, as many people are afflicted with severe gastrointestinal diseases worldwide, but most don’t have this particular, potent toxic germ. Cholera spreads by contamination of infected human feces in the water supply. The disease can afflict people who drink tainted water, who touch it and then put unclean fingers into their mouths, as children do, and who eat food prepared by those with affected hands.

illustration by Robert Seymour (1831), image from the National Library of Medicine, image A021786

Choleraphoby, illustration by Robert Seymour (1831), lithograph from the National Library of Medicine, Image #A021786

Dr. John Snow, an anesthesiologist and founder of public health, recognized the means of cholera’s spread more than 150 years ago in London, where he became famous for mandating the closure of the Broad Street Pump. Snow died at the age of 45, of what was said to be apoplexy, old jargon for a stroke.

In 2009, there were 221,226 cholera cases reported and 4,946 cholera deaths in 45 countries, according to the CDC. Based on information put together by the World Health Organization, the case-fatality rate is 2.24%. A trend in recent years is that the overwhelming majority of cases, roughly 99 percent, are reported in Africa.

According to the 17th edition of Harrison’s Principles of Internal Medicine, there have been seven global cholera pandemics since 1817. The current rage, attributed primarily to the El Tor biotype, started in Indonesia around 1961. That strain spread, eventually, as far as coastal Peru in the early 1990s. There have been no cholera epidemics in North America since the middle of the 19th Century.

What’s happening in Haiti now is the real deal, says the CDC. Thousands are infected, mainly in towns along the Artibonite River, which squiggles on the map and in real terrain through the western section of Hispaniola, north of Haiti’s capital, Port-Au-Prince. Among other concerns are the vast numbers of people living without toilets in tent cities and slums outside of the capital, especially since an earthquake devastated the region last January.

The CDC offers some very practical tips for people who live or travel in areas where cholera is endemic. Most people who are exposed to cholera and survive become immune, although infectious strains vary and immunity may not be long-lasting. In the U.S. there is no available vaccine for cholera, according to the CDC. Treatment consists primarily of giving electrolyte solutions, for rehydration, and antibiotics in some cases.

Now, the mortality rate from cholera in Haiti is running just under 10 percent, according to today’s news. Hopefully, doctors from MSF and other agencies working in the region will get this epidemic under control. But already it’s clear that hundreds of lives have been lost to an illness that it seems should have been eradicated long ago.

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